Real-World Insights into Evolocumab Use in Patients with Hyperlipidemia Across Five Countries: Analysis from the ZERBINI Study.

INTRODUCTION: This study characterizes patients receiving evolocumab in clinical practice and assesses treatment effectiveness, safety and persistence outcomes across five countries. METHODS: This retrospective and prospective observational study enrolled patients initiated on evolocumab during August 2017 to July 2019 at 49 sites across Canada, Mexico, Colombia, Saudi Arabia and Kuwait. Medical records data were extracted within 6 months prior to (baseline) and every 3 months for 12 months post evolocumab initiation and reported as available. RESULTS: A total of 578 patients were enrolled (40.1% female, median age 60 [interquartile range (IQR) 51-68] years); 83.7% had atherosclerotic cardiovascular disease and/or familial hypercholesterolemia. Median low-density lipoprotein cholesterol (LDL-C) at baseline was 3.4 (IQR 2.7-4.2) mmol/L (131.5 [IQR 104.4-162.4] mg/dL), with 75.6% of patients receiving a statin (59.2% high intensity). Compared to baseline, the median lowest LDL-C was reduced by 70.2% and remained stable over 12 months of treatment. Guideline-recommended LDL-C thresholds < 1.8, < 1.4 and < 1.0 mmol/L (< 70, < 55 and < 40 mg/dL) were achieved by 75.3%, 63.6% and 47.4% of patients. LDL-C outcomes were consistent across high- and very high-risk patients. Background lipid-lowering therapy remained relatively stable. No serious treatment-emergent adverse events were reported, and persistence to evolocumab was 90.2% at 12 months. CONCLUSION: These findings provide real-world evidence that evolocumab use is in accordance with its international guideline-recommended place in dyslipidemia therapy, as well as confirmation of its effectiveness and safety in a heterogeneous population. Evolocumab can address a healthcare gap in the management of dyslipidemia by increasing the proportion of patients achieving LDL-C goals recommended to lower cardiovascular risk.

Awareness Among Primary Care Physicians in Canada of Guideline Recommendations for Lowering LDL-Cholesterol in High-Risk Patients.

Background: Cardiovascular (CV) risk management for high-risk patients is often provided by primary care physicians (PCPs). We surveyed Canadian PCPs regarding their awareness and implementation of the 2021 Canadian Cardiovascular Society (CCS) lipid guideline recommendations for patients following an acute coronary syndrome (ACS) and those with diabetes but without CV disease. Methods: A committee of PCPs and specialists with lipid expertise, including some 2021 CCS lipid guideline coauthors, designed a survey to probe PCP awareness and practice patterns regarding CV risk management. From a national database, a total of 250 PCPs completed the survey between January and April 2022. Results: Almost all PCPs (97.2%) concurred that a post-ACS patient should be seen by their PCP within 4 weeks of hospital discharge (81.2% said within 2 weeks). Almost half (44.4%) responded that discharge summaries provided inadequate information, and 41.6% felt that lipid management post-ACS was the responsibility primarily of specialists. A total of 58.4% articulated that they face challenges when seeing a post-ACS patient, related to inadequate discharge information, complexities of polypharmacy and duration of therapies, and managing statin intolerance. A total of 63.2% and 43.6% correctly identified low-density lipoprotein cholesterol (LDL-C) intensification thresholds of 1.8 mmol/L in post-ACS patients, and 2.0 mmol/L in diabetes patients, respectively, and 81.2% incorrectly thought that proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors were indicated for patients with diabetes but without CV disease. Conclusions: One year following publication of the 2021 CCS lipid guidelines, our survey reveals knowledge gaps among responding PCPs regarding intensification thresholds and treatment options for patients post-ACS, or those with diabetes. Innovative and effective knowledge-translation programs to address these gaps are desirable.

Contexte: La prise en charge du risque cardiovasculaire (CV) chez les patients à risque élevé est souvent réalisée par les médecins en soins primaires (MSP). Nous avons donc sondé les MSP canadiens quant à leur connaissance des lignes directrices 2021 de la Société cardiovasculaire du Canada (SCC) sur les lipides et leur mise en œuvre auprès des patients ayant subi un syndrome coronarien aigu (SCA) et auprès des patients atteints de diabète qui ne présentent pas de maladie CV. Méthodologie: Un comité de MSP et de spécialistes ayant une expertise sur la question des lipides, y compris certains coauteurs des lignes directrices 2021 de la SCC sur les lipides, a conçu un sondage pour évaluer la connaissance des mesures de prise en charge du risque CV et les habitudes de pratique des MSP en la matière. Au total, 250 MSP provenant d'une banque de données nationale ont rempli le sondage entre janvier et avril 2022. Résultats: Presque tous les MSP (97,2 %) étaient d'accord pour dire que les patients ayant subi un SCA devraient avoir une consultation avec leur MSP dans les quatre semaines suivant leur congé de l'hôpital (81,2 % ont dit deux semaines). Près de la moitié des répondants (44,4 %) ont indiqué que le sommaire d'hospitalisation fournit une information inadéquate, et 41,6 % estimaient que la gestion des lipides après un SCA relevait des spécialistes. Au total, 58,4 % des répondants ont mentionné rencontrer des difficultés lors de la consultation avec un patient après une SCA, surtout quant à l'information inadéquate contenue dans le sommaire d'hospitalisation, aux complexités de la polypharmacie, à la durée des traitements et à l'intolérance aux statines. De plus, 63,2 % et 43,6 % des répondants ont correctement indiqué les seuils d'intensification du traitement pour le cholestérol à lipoprotéines de basse densité (LDL), soit 1,8 mmol/l chez les patients après un SCA et 2,0 mmol/l chez les patients diabétiques, respectivement. Par ailleurs, 81,2 % des répondants croyaient à tort que les inhibiteurs de la proprotéine convertase subtilisine/kexine de type 9 (PCSK9) étaient indiqués pour les patients diabétiques ne présentant pas de maladie CV. Conclusions: Un an après la publication des lignes directrices 2021 de la SCC sur les lipides, notre sondage montre des lacunes dans les connaissances des MSP quant aux seuils d'intensification du traitement et aux options de traitement pour les patients ayant subi un SCA ou atteints de diabète. Des programmes novateurs et efficaces de transmission du savoir sont souhaitables pour combler ces lacunes.

The association of maternal sugary beverage consumption during pregnancy and the early years with childhood sugary beverage consumption.

OBJECTIVES: A woman's food choices during pregnancy may be associated with her offspring's food choices. Several studies support an association between childhood sugary beverage (SB) consumption and poor cardiometabolic health. This study aimed to assess the association of maternal SB consumption during pregnancy and later, with her offspring's SB consumption in early infancy and childhood. METHODS: A total of 1945 women and 1595 children participating in 3 Canadian studies reported SB consumption during pregnancy, at 2 years of age, and/or at school age (5 to 8 years old). Mother and offspring SB intakes were self-reported by mothers. Multivariable linear regression analyses were conducted within each cohort and cohort data were combined using fixed effect meta-analyses. RESULTS: Maternal SB consumption during pregnancy was associated with higher offspring SB consumption at 2 years of age (standardized ß = 0.19 predicted change in the number of standard deviations of offspring SB intake for an increase of 1 standard deviation in maternal serving [95% CI: 0.16 to 0.22]). Concurrent maternal SB consumption was associated with higher offspring SB intake when children were aged 5 to 8 years (standardized ß= 0.25 [95% CI: 0.10 to 0.40]). CONCLUSION: Maternal SB consumption during pregnancy is associated with a marginally higher SB intake among their offspring at age 2, and concurrent maternal consumption is associated with a higher SB intake among school-aged offspring (5 to 8 years old). Future interventions tailored for pregnancy and early childrearing years to reduce SB intakes of mothers may reduce young children's SB intake.

RéSUMé: OBJECTIFS: Il peut y avoir un lien entre les choix alimentaires d'une femme pendant la grossesse et ceux de son enfant. Plusieurs études font état d'une association entre la consommation de boissons sucrées (BS) durant l'enfance et la mauvaise santé cardiométabolique. Notre étude visait à évaluer l'association entre la consommation de BS des mères pendant et après la grossesse et la consommation de BS de leurs enfants durant la petite enfance et l'enfance. MéTHODE: En tout, 1 945 femmes et 1 595 enfants participant à 3 études canadiennes ont fait état de leur consommation de BS pendant la grossesse, à l'âge de 2 ans et/ou à l'âge scolaire (5 à 8 ans). La consommation de BS des mères et des enfants a été déclarée par les mères. Des analyses de régression linéaire multivariée ont été menées dans chaque cohorte, et les données des cohortes ont été combinées à l'aide de méta-analyses à effets fixes. RéSULTATS: La consommation maternelle de BS pendant la grossesse était associée à une consommation de BS plus élevée chez les enfants à l'âge de 2 ans (le coefficient ß standardisé = 0,19 prédisait le changement du nombre d'écart-types de consommation de BS chez les enfants pour chaque hausse de 1 écart-type de la portion maternelle [IC de 95 % : 0,16 à 0,22]). La consommation maternelle concomitante de BS était associée à une consommation de BS plus élevée chez les enfants lorsqu'ils étaient âgés de 5 à 8 ans (coefficient ß standardisé = 0,25 [IC de 95 % : 0,10 à 0,40]). CONCLUSION: La consommation maternelle de BS pendant la grossesse est associée à une consommation de BS marginalement plus élevée chez l'enfant à l'âge de 2 ans, et la consommation maternelle concomitante est associée à une consommation de BS plus élevée chez l'enfant d'âge scolaire (5 à 8 ans). De futures interventions visant à réduire la consommation de BS des mères pendant la grossesse et durant les premières années où elles élèvent leurs enfants pourraient réduire la consommation de BS des jeunes enfants.

Epidemiology of COVID-19 and Its Cardiac and Neurologic Complications Among Chinese and South Asians in Ontario: Waves 1, 2, and 3.

Background: Although we had previously reported the cardiac and neurologic outcomes of Chinese and South Asian Ontarians in wave 1 of COVID-19, data on subsequent waves of COVID-19 remain unexamined. This is an extension study of this cohort in waves 2 and 3. Methods: We identified adult Ontarians with a positive COVID-19 polymerase chain reaction test from January 1, 2020 to June 30, 2021, and they were classified as being Chinese or South Asian using a validated surname algorithm; we compared their outcomes of mortality, and cardiac and neurologic complications with those of the general population using multivariable logistic regression models. Results: Compared to the general population (n = 439,977), the Chinese population (n = 15,208) was older (mean age 44.2 vs 40.6 years, P < 0.001) and the South Asian population (n = 46,333) was younger (39.2 years, P < 0.001). The Chinese population had a higher 30-day mortality (odds ratio [OR] 1.44; 95% confidence interval [CI] 1.28-1.61) and more hospitalization or emergency department visits (OR, 1.14; 95% CI, 1.09-1.28), with a trend toward a higher incidence of cardiac complications (OR, 1.03; 95% CI, 0.87-1.12) and neurologic complications (OR, 1.23; 95% CI, 0.96-1.58). South Asians had a lower 30-day mortality (OR, 0.88; 95% CI, 0.78-0.98) but a higher incidence of hospitalization or emergency department visits (OR, 1.17; 95% CI, 1.14-1.20) with a trend toward a lower incidence of cardiac complications (OR, 0.76; 95% CI, 0.67-0.87) and neurologic complications (OR, 0.89; 95% CI, 0.73-1.09). There was also a significant difference in these outcomes between wave 1, 2 and 3, with a greater mortality in all groups in waves 2 and 3. Conclusions: Ethnicity continues to be an important determinant of mortality, cardiac and neurologic outcomes, and healthcare use among patients with COVID-19, requiring further studies to understand factors driving these differences.

Contexte: Nous avons déjà présenté les issues cliniques cardiaques et neurologiques chez les Ontariens de descendance chinoise ou sud-asiatique pour la première vague de la pandémie de COVID-19, mais les données au sujet des vagues ultérieures n'avaient pas encore été analysées. Nous présentons ici une prolongation de cette étude de cohortes pour la seconde et la troisième vague de COVID-19. Méthodologie: Notre analyse porte sur des adultes ontariens ayant obtenu un résultat positif à un test de COVID-19 par réaction en chaîne de la polymérase entre le 1er janvier 2020 et le 30 juin 2021. Un algorithme validé pour l'analyse des noms de famille a été utilisé pour isoler les sujets de descendance chinoise ou sud-asiatique, et leur taux de mortalité de même que les complications cardiaques et neurologiques ont été comparés à ceux de la population générale à l'aide de modèles de régression logistique multivariée. Résultats: En comparaison de la population générale (n = 439 977), les personnes de descendance chinoise (n = 15 208) se sont révélées plus âgées (âge moyen de 44,2 ans contre 40,6 ans, P < 0,001), tandis que les personnes de descendance sud-asiatique (n = 46 333) étaient plus jeunes (39,2 ans, P < 0,001). Dans la population de descendance chinoise, le taux de mortalité après 30 jours était plus élevé (rapport de cotes [RC] de 1,44; intervalle de confiance [IC] à 95 % de 1,28 à 1,61), et davantage d'hospitalisations ou de consultations aux urgences sont survenues (RC de 1,14; IC à 95 % de 1,09 à 1,28). L'incidence de complications cardiaques (RC de 1,03; IC à 95 % de 0,87 à 1,12) et de complications neurologiques (RC de 1,23; IC à 95 % de 0,96 à 1,58) avait également tendance à être plus élevée. Chez les personnes de descendance sud-asiatique, le taux de mortalité après 30 jours était plus faible (RC de 0,88; IC à 95 % de 0,78 à 0,98), mais l'incidence d'hospitalisations ou de consultations aux urgences était plus élevée (RC de 1,17; IC à 95 % de 1,14 à 1,20). Elles présentaient également une tendance vers une plus faible incidence de complications cardiaques (RC de 0,76; IC à 95 % de 0,67 à 0,87) et de complications neurologiques (RC de 0,89; IC à 95 % de 0,73 à 1,09). Des différences significatives ont également été observées pour ces paramètres entre les vagues 1, 2 et 3 de la maladie, et le taux de mortalité était plus élevé pour tous les groupes des vagues 2 et 3. Conclusions: L'origine ethnique demeure un déterminant important de la mortalité, des issues cliniques cardiaques et neurologiques ainsi que de l'utilisation des ressources en santé chez les patients atteints de la COVID-19. D'autres études sont toutefois nécessaires pour mieux comprendre les facteurs qui expliquent ces différences.

Real-World Insights Into Evolocumab Use in Patients With Hyperlipidemia: Canadian Analysis From the ZERBINI Study.

Background: The 2021 Canadian Cardiovascular Society guidelines recommend proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor therapy in patients with atherosclerotic cardiovascular disease whose low-density lipoprotein cholesterol (LDL-C) concentration remains ≥ 1.8 mmol/L despite maximally tolerated statin therapy. This retrospective and prospective observational study characterizes Canadian patients treated with evolocumab and describes its effectiveness and safety. Methods: Between August 2017 and July 2019, a total of 131 patients initiated on evolocumab therapy were enrolled at 15 sites in Canada. Data were extracted from medical records every 3 months between 6 months prior to, and for 12 months following evolocumab therapy initiation, until July 6, 2020. Baseline and prospectively collected data are reported as available. Results: A total of 131 patients were enrolled (59.5% male; mean age [standard deviation (SD)] 64.7 ± 10.6 years), most with a diagnosis of atherosclerotic cardiovascular disease and/or familial hypercholesterolemia (93.4%). Mean (± SD) LDL-C concentration at baseline was 3.7 (± 1.7) mmol/L (n = 119), with 58.0% of patients receiving a statin (36.6% high intensity). Mean (± SD) LDL-C concentration after evolocumab treatment was 1.6 (± 1.0) mmol/L (n = 120), representing a 58.7% decrease from baseline (n = 109). This level remained stable over 12 months. An LDL-C concentration < 1.8 mmol/L was achieved by 77.5% of patients. Persistence was 92%, and no serious treatment-emergent adverse events were reported. Conclusions: These findings provide real-world evidence of guideline-recommended initiation of evolocumab therapy, as well as confirmation of its effectiveness and safety in a Canadian population. Evolocumab therapy can address a healthcare gap in the management of dyslipidemia, by increasing the proportion of patients achieving LDL-C goals recommended to lower cardiovascular risk.

Introduction: Les lignes directrices de la Société canadienne de cardiologie de 2021 recommandent un traitement par les inhibiteurs de proprotéine convertase subtilisine-kexine de type 9 (PCSK9) aux patients atteints de la maladie cardiovasculaire athérosclérotique chez lesquels les concentrations de cholestérol à lipoprotéines de faible densité (cholestérol LDL) demeurent ≥ 1,8 mmol/l malgré le traitement maximalement toléré par statines. La présente étude observationnelle rétrospective et prospective donne les caractéristiques des patients canadiens traités par évolocumab, et décrit l'efficacité et l'innocuité de ce médicament. Méthodes: Entre août 2017 et juillet 2019, nous avons inscrit un total de 131 patients qui avaient amorcé le traitement d'évolocumab dans 15 établissements du Canada. Nous avons extrait les données des dossiers médicaux tous les trois mois de six mois avant et jusqu'à 12 mois après le début du traitement par évolocumab, et ce, jusqu'au 6 juillet 2020. Les données initiales et les données collectées de façon prospective sont déclarées selon leur disponibilité. Résultats: Nous avons inscrit un total de 131 patients (59,5 % d'hommes; âge moyen [écart type (ET)] 64,7 ± 10,6 ans); la plupart avaient un diagnostic de maladie cardiovasculaire athérosclérotique et/ou d'hypercholestérolémie familiale (93,4 %). Les concentrations initiales moyennes (± ET) de cholestérol LDL étaient de 3,7 (± 1,7) mmol/l (n = 119), et 58,0 % des patients recevaient une statine (36,6 % d'intensité élevée). Les concentrations moyennes (± ET) de cholestérol LDL après le traitement par évolocumab étaient de 1,6 (± 1,0) mmol/l (n = 120), soit une diminution de 58,7 % par rapport aux concentrations initiales (n = 109). Ces concentrations sont demeurées stables durant 12 mois. Des concentrations de cholestérol LDL < 1,8 mmol/l ont été atteintes par 77,5 % des patients. La persistance a été de 92 %, et aucun événement défavorable sérieux associé au traitement n'a été déclaré. Conclusions: Ces résultats fournissent des données probantes du monde réel sur l'amorce du traitement par évolocumab conformément aux recommandations des lignes directrices, ainsi qu'une confirmation de son efficacité et de son innocuité au sein d'une population canadienne. Le traitement par évolocumab peut permettre de remédier aux lacunes des soins de santé dans la prise en charge de la dyslipidémie par l'augmentation de la proportion de patients atteignant les objectifs recommandés en matière de cholestérol LDL pour réduire le risque de maladies cardiovasculaires.

The Morphology of Coronary Artery Disease in South Asians vs White Caucasians and Its Implications.

South Asians (SAs) experience a higher prevalence and earlier onset of coronary artery disease and have worse outcomes compared with White Caucasians (WCs) following invasive revascularisation procedures, a mainstay of coronary artery disease (CAD) management. We sought to review the differences in the CAD pattern and risk factors between SA and WC patients and to discuss their potential impact on the development of coronary disease, acute coronary syndrome, and revascularisation outcomes. SAs have a more diffuse pattern with multivessel involvement compared with WCs. However, less is known about other morphologic characteristics, such as calcification of atherosclerotic plaque and coronary diameter in SA populations. Despite a similar coronary calcification burden, higher noncalcified plaque composition, elevated thrombosis, and inflammatory markers likely contribute to the disease pattern. Although the current evidence on the role of coronary vessel size remains inconsistent, smaller diameters in SAs could play a potential role in the higher disease prevalence. This is especially important given the impact of coronary artery diameter on revascularisation outcomes. In conclusion, SAs have a unique CAD risk profile composed of traditional and novel risk factors. Our findings highlight the need for additional awareness of health professionals of this specific risk profile and potential therapeutic targets, as well as the need for further research in this vulnerable population.

Serum metabolomic signatures of gestational diabetes in South Asian and white European women.

INTRODUCTION: This study aimed to identify serum metabolomic signatures associated with gestational diabetes mellitus (GDM), and to examine if ethnic-specific differences exist between South Asian and white European women. RESEARCH DESIGN AND METHODS: Prospective cohort study with a nested case-control analysis of 600 pregnant women from two Canadian birth cohorts; using an untargeted approach, 63 fasting serum metabolites were measured and analyzed using multisegment injection-capillary electrophoresis-mass spectrometry. Multivariate logistic regression modeling was conducted overall and by cohort. RESULTS: The proportion of women with GDM was higher in South Asians (27.1%) compared with white Europeans (17.9%). Several amino acid, carbohydrate, and lipid pathways related to GDM were common to South Asian and white European women. Elevated circulating concentrations of glutamic acid, propionylcarnitine, tryptophan, arginine, 2-hydroxybutyric acid, 3-hydroxybutyric acid, and 3-methyl-2-oxovaleric acid were associated with higher odds of GDM, while higher glutamine, ornithine, oxoproline, cystine, glycine with lower odds of GDM. Per SD increase in glucose concentration, the odds of GDM increased (OR=2.07, 95% CI 1.58 to 2.71), similarly for metabolite ratios: glucose to glutamine (OR=2.15, 95% CI 1.65 to 2.80), glucose to creatinine (OR=1.79, 95% CI 1.39 to 2.32), and glutamic acid to glutamine (OR=1.46, 95% CI 1.16 to 1.83). South Asians had higher circulating ratios of glucose to glutamine, glucose to creatinine, arginine to ornithine, and citrulline to ornithine, compared with white Europeans. CONCLUSIONS: We identified a panel of serum metabolites implicated in GDM pathophysiology, consistent in South Asian and white European women. The metabolic alterations leading to larger ratios of glucose to glutamine, glucose to creatinine, arginine to ornithine, and citrulline to ornithine in South Asians likely reflect the greater burden of GDM among South Asians compared with white Europeans.

Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): an international, open-label, randomised, controlled trial.

BACKGROUND: Dietary restriction of sodium has been suggested to prevent fluid overload and adverse outcomes for patients with heart failure. We designed the Study of Dietary Intervention under 100 mmol in Heart Failure (SODIUM-HF) to test whether or not a reduction in dietary sodium reduces the incidence of future clinical events. METHODS: SODIUM-HF is an international, open-label, randomised, controlled trial that enrolled patients at 26 sites in six countries (Australia, Canada, Chile, Colombia, Mexico, and New Zealand). Eligible patients were aged 18 years or older, with chronic heart failure (New York Heart Association [NYHA] functional class 2-3), and receiving optimally tolerated guideline-directed medical treatment. Patients were randomly assigned (1:1), using a standard number generator and varying block sizes of two, four, or six, stratified by site, to either usual care according to local guidelines or a low sodium diet of less than 100 mmol (ie, <1500 mg/day). The primary outcome was the composite of cardiovascular-related admission to hospital, cardiovascular-related emergency department visit, or all-cause death within 12 months in the intention-to-treat (ITT) population (ie, all randomly assigned patients). Safety was assessed in the ITT population. This study is registered with ClinicalTrials.gov, NCT02012179, and is closed to accrual. FINDINGS: Between March 24, 2014, and Dec 9, 2020, 806 patients were randomly assigned to a low sodium diet (n=397) or usual care (n=409). Median age was 67 years (IQR 58-74) and 268 (33%) were women and 538 (66%) were men. Between baseline and 12 months, the median sodium intake decreased from 2286 mg/day (IQR 1653-3005) to 1658 mg/day (1301-2189) in the low sodium group and from 2119 mg/day (1673-2804) to 2073 mg/day (1541-2900) in the usual care group. By 12 months, events comprising the primary outcome had occurred in 60 (15%) of 397 patients in the low sodium diet group and 70 (17%) of 409 in the usual care group (hazard ratio [HR] 0·89 [95% CI 0·63-1·26]; p=0·53). All-cause death occurred in 22 (6%) patients in the low sodium diet group and 17 (4%) in the usual care group (HR 1·38 [0·73-2·60]; p=0·32), cardiovascular-related hospitalisation occurred in 40 (10%) patients in the low sodium diet group and 51 (12%) patients in the usual care group (HR 0·82 [0·54-1·24]; p=0·36), and cardiovascular-related emergency department visits occurred in 17 (4%) patients in the low sodium diet group and 15 (4%) patients in the usual care group (HR 1·21 [0·60-2·41]; p=0·60). No safety events related to the study treatment were reported in either group. INTERPRETATION: In ambulatory patients with heart failure, a dietary intervention to reduce sodium intake did not reduce clinical events. FUNDING: Canadian Institutes of Health Research and the University Hospital Foundation, Edmonton, Alberta, Canada, and Health Research Council of New Zealand.

Relationship of parental feeding practices and diet with children's diet among South Asians in Canada.

BACKGROUND: South Asian children's diets are considered unhealthy, yet the relationship with food parenting among South Asians is understudied. METHODS: In a cross-sectional study, questionnaires were administered to dyads of Canadian South Asian elementary and high school children and a parent. Relationships between parental factors (perceived responsibility, restriction, pressure to eat, monitoring, home food environment, nutrition knowledge and intake of fruits and vegetables (FV), sugary beverages (SB) and sweets and fast foods (SWFF) and children's intake of FV, SB and SWFF were assessed by linear regression adjusted for sociodemographics. Subgroup differences by children's age and acculturation were explored by interaction analysis. RESULTS: 291 children (age 9.8 ± 3.2 years) had mean daily intake frequencies of 3.1 ± 2.0 FV, 1.0 ± 0.9 SB and 2.1 ± 1.5 SWFF. Positive associations were found between parent and child intake of FV (standardized beta (ß) = 0.230, [95%CI 0.115, 0.345], p < 0.001), SB (ß = 0.136 [0.019, 0.252], p = 0.02), and SWFF (ß = 0.167 [0.052, 0.282], p = 0.005). Parental monitoring was associated with lower children's SWFF intake (ß = -0.131 [-0.248, -0.015], p = 0.03). Among those expressing less Western culture, parental SWFF intake was associated with child's SB intake (ß = 0.255 [0.085, 0.425], p = 0.004). Among those expressing less traditional culture, positive home food environment was associated with lower child SWFF intake (ß = -0.208 [-0.374, -0.042], p = 0.015). CONCLUSION: South Asian children's diets have stronger relationships with their parents' diets than with food parenting practices or nutrition knowledge, though parental monitoring was associated with lower unhealthy food intake. However, with greater acculturation, the home food environment was more important for unhealthy food intake.

2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults.

The 2021 guidelines primary panel selected clinically relevant questions and produced updated recommendations, on the basis of important new findings that have emerged since the 2016 guidelines. In patients with clinical atherosclerosis, abdominal aortic aneurysm, most patients with diabetes or chronic kidney disease, and those with low-density lipoprotein cholesterol ≥ 5 mmol/L, statin therapy continues to be recommended. We have introduced the concept of lipid/lipoprotein treatment thresholds for intensifying lipid-lowering therapy with nonstatin agents, and have identified the secondary prevention patients who have been shown to derive the largest benefit from intensification of therapy with these agents. For all other patients, we emphasize risk assessment linked to lipid/lipoprotein evaluation to optimize clinical decision-making. Lipoprotein(a) measurement is now recommended once in a patient's lifetime, as part of initial lipid screening to assess cardiovascular risk. For any patient with triglycerides ˃ 1.5 mmol/L, either non-high-density lipoprotein cholesterol or apolipoprotein B are the preferred lipid parameter for screening, rather than low-density lipoprotein cholesterol. We provide updated recommendations regarding the role of coronary artery calcium scoring as a clinical decision tool to aid the decision to initiate statin therapy. There are new recommendations on the preventative care of women with hypertensive disorders of pregnancy. Health behaviour modification, including regular exercise and a heart-healthy diet, remain the cornerstone of cardiovascular disease prevention. These guidelines are intended to provide a platform for meaningful conversation and shared-decision making between patient and care provider, so that individual decisions can be made for risk screening, assessment, and treatment.

Physician Perspectives on the Diagnosis and Management of Heart Failure With Preserved Ejection Fraction.

BACKGROUND: Heart failure (HF) with preserved ejection fraction (HFpEF) carries high morbidity and mortality. Compared with HF with reduced ejection fraction (HFrEF), HFpEF is difficult to diagnose, and lacks evidence-based treatments. In this survey we assessed perceptions of cardiologists, internists, and primary care physicians (PCPs) regarding HFpEF diagnosis and management. METHODS: In total, 159 cardiologists, 89 internists, and 200 PCPs from across Canada completed an online survey, with response rates of 14%-17%. RESULTS: The perceived prevalence of HFpEF vs HFrEF was similar across physician types (58% HFrEF, 42% HFpEF). Thirty-seven percent of PCPs did not differentiate HF on the basis of ejection fraction. All physician types ranked symptom and mortality reduction as treatment priorities. Ninety-two percent of specialists believed that HFpEF is best comanaged by PCPs and specialists, whereas one-fifth of PCPs suggested PCP management alone. Compared with specialists, PCPs were more likely to underestimate HFpEF mortality and less aware of sex differences in the prevalence of HFpEF vs HFrEF (all P < 0.001). Fewer PCPs use natriuretic peptides for diagnosis (P < 0.001). All physician types listed cost and availability as barriers to natriuretic peptide use. Ninety-one percent of PCPs incorrectly identified various therapies as effective for improving HFpEF outcomes. Most of all physicians expressed a strong desire to increase knowledge of diagnostic and treatment algorithms for HFpEF. CONCLUSIONS: There are substantial knowledge gaps in the diagnosis and management of HFpEF, particularly among PCPs. Because of the prevalence of HFpEF in primary care, strategies are required to reduce these gaps.

INTRODUCTION: L'insuffisance cardiaque (IC) à fraction d'éjection préservée (ICFEP) entraîne des taux élevés de morbidité et de mortalité. Comparativement à l'IC à fraction d'éjection réduite (ICFER), il est difficile de poser le diagnostic de l'ICFEP et de trouver des traitements fondés sur des données probantes. Dans cette enquête, nous avons évalué la perception des cardiologues, des internistes et des médecins de premier recours (MPR) concernant le diagnostic et la prise en charge de l'ICFEP. MÉTHODES: Au total, 159 cardiologues, 89 internistes et 200 MPR du Canada ont rempli l'enquête en ligne. Le taux de réponse a été de 14 % à 17 %. RÉSULTATS: Tous les types de médecins percevaient une prévalence similaire entre l'ICFEP et l'ICFER (58 % ICFER, 42 % ICFEP). Trente-sept pour cent des MPR ne différenciaient pas l'IC en fonction de la fraction d'éjection. Tous les types de médecins donnaient la priorité de traitement à la réduction des symptômes et de la mortalité. Quatre-vingt-douze pour cent des spécialistes croyaient que la prise en charge commune de l'ICFEP par les MPR et les spécialistes était préférable, tandis qu'un cinquième des MPR suggéraient une prise en charge par le MPR seul. Comparativement aux spécialistes, il était plus probable que les MPR sous-estiment la mortalité liée à l'ICFEP et qu'ils soient moins au fait des différences entre les sexes dans la prévalence de l'ICFEP vs l'ICFER (toutes les valeurs p < 0,001). Un plus petit nombre de MPR utilisent les peptides natriurétiques pour le diagnostic (P < 0,001). Tous les types de médecins ont considéré les coûts et la disponibilité comme des obstacles à l'utilisation des peptides natriurétiques. Quatre-vingt-onze pour cent des MPR ont considéré à tort que les diverses thérapies étaient efficaces pour améliorer les résultats de l'ICFEP. La plupart des médecins ont fait part de leur profond désir de rehausser leurs connaissances sur les algorithmes diagnostiques et thérapeutiques de l'ICFEP. CONCLUSIONS: Il existe des lacunes substantielles dans les connaissances en matière de diagnostic et de prise en charge de l'ICFEP, particulièrement des lacunes dans les connaissances des MPR. En raison de la prévalence de l'ICFEP dans les soins primaires, des stratégies sont nécessaires pour combler ces lacunes.

Landscape of Lipid Management Following an Acute Coronary Syndrome Event: Survey of Canadian Specialists.

BACKGROUND: Following the occurrence of an acute coronary syndrome (ACS), patients are at high risk for subsequent cardiovascular events. Therapies to lower the level of low-density lipoprotein (LDL) cholesterol remain a pillar in secondary prevention approaches following ACS. Significant variability remains in the application of therapies to lower cholesterol level in clinical practice. METHODS: A cross-sectional, online survey was conducted of 200 cardiovascular and lipid specialists across Canada who routinely care for patients following the occurrence of ACSs. The survey consisted of 50 multiple-choice questions with opportunities for free-text entry exploring knowledge of lipid guidelines and recent clinical trials, and in-hospital and outpatient management of lipids and familial hypercholesterolemia. RESULTS: A total of 67.5% (n = 135) of participants stated that a lipid panel would routinely be obtained during the first 24 hours of an admission for an ACS, and 68.5% (n = 137) stated that their hospitals had standing orders for statin initiation at ACS presentation. In high-risk patients, the majority (75.5%; n = 151) of participants indicated that they target an LDL cholesterol level of <1.8 mmol/L. However, a subset (22%; n = 44) would target lower LDL cholesterol levels ranging from 0.5 to 1.7 mmol/L. Only 32.0% (n = 64) of participants stated that >70% of their ACS patients were at or below guideline-recommended LDL cholesterol levels. Respondents generally underappreciated the prevalence of familial hypercholesterolemia in both the general population and ACS patients. CONCLUSIONS: There is significant variation in practice patterns involving therapies to lower LDL cholesterol level in the post-ACS onset period. To improve management of lipids in this high-risk population, changes to institutional policies, shared responsibility of lipid management across multiple disciplines, and physician education are required.

CONTEXTE: Après un syndrome coronarien aigu (SCA), le risque qu'un autre événement cardiovasculaire survienne est élevé. Les traitements visant à réduire le taux de cholestérol des lipoprotéines de basse densité (C-LDL) demeurent l'un des piliers de la prévention secondaire après un SCA. Dans la pratique clinique, l'utilisation de ces traitements varie considérablement d'un praticien à l'autre. MÉTHODOLOGIE: Nous avons mené une enquête transversale en ligne auprès de 200 spécialistes de la santé cardiovasculaire et des lipides de partout au Canada, qui traitent régulièrement des patients ayant subi un SCA. L'enquête comprenait 50 questions à choix multiples; les participants pouvaient aussi donner des réponses détaillées permettant d'évaluer leurs connaissances des lignes directrices en matière de maîtrise des lipides et des essais cliniques récents, ainsi que de la prise en charge de la lipidémie et de l'hypercholestérolémie familiale en contexte hospitalier et ambulatoire. RÉSULTATS: Au total, 67,5 % (n = 135) des participants ont déclaré demander systématiquement un bilan lipidique complet dans les 24 heures suivant l'admission d'un patient en raison d'un SCA, et 68,5 % (n = 137) des participants ont dit que la norme dans leur hôpital était d'instaurer un traitement par statine chez tous les patients ayant subi un SCA. Dans le cas des patients présentant un risque élevé, la majorité des participants (75,5 %, n = 151) ont indiqué qu'ils ciblaient un taux de C-LDL de moins de 1,8 mmol/l. Une partie de ces répondants (22 %; n = 4) ont dit cibler un taux de C-LDL encore plus bas, soit de 0,5 à 1,7 mmol/l. Seulement 32,0 % (n = 64) des répondants ont déclaré que plus de 70 % de leurs patients ayant subi un SCA avaient un taux de C-LDL à la limite ou en deçà du taux recommandé dans les lignes directrices. Les répondants ont en général sous-estimé la prévalence de l'hypercholestérolémie familiale dans la population générale et chez les patients ayant subi un SCA. CONCLUSIONS: Les pratiques varient considérablement d'un praticien à l'autre en ce qui concerne les traitements visant à diminuer le taux de C-LDL après la survenue d'un SCA. Afin d'améliorer la prise en charge de la lipidémie dans cette population exposée à un risque élevé, il conviendrait de revoir les politiques des établissements, de répartir la responsabilité de la prise en charge de la lipidémie entre les intervenants de différentes disciplines et de mieux informer les médecins.

Maternal Diet and the Serum Metabolome in Pregnancy: Robust Dietary Biomarkers Generalizable to a Multiethnic Birth Cohort.

BACKGROUND: Advances in metabolomics are anticipated to decipher associations between dietary exposures and health. Replication biomarker studies in different populations are critical to demonstrate generalizability. OBJECTIVES: To identify and validate robust serum metabolites associated with diet quality and specific foods in a multiethnic cohort of pregnant women. DESIGN: In this cross-sectional analysis of 3 multiethnic Canadian birth cohorts, we collected semiquantitative FFQ and serum data from 900 women at the second trimester of pregnancy. We calculated a diet quality score (DQS), defined as daily servings of "healthy" minus "unhealthy" foods. Serum metabolomics was performed by multisegment injection-capillary electrophoresis-mass spectrometry, and specific serum metabolites associated with maternal DQSs were identified. We combined the results across all 3 cohorts using meta-analysis to classify robust dietary biomarkers (r > ± 0.1; P < 0.05). RESULTS: Diet quality was higher in the South Asian birth cohort (mean DQS = 7.1) than the 2 white Caucasian birth cohorts (mean DQS <3.2). Sixty-six metabolites were detected with high frequency (>75%) and adequate precision (CV <30%), and 47 were common to all cohorts. Hippuric acid was positively associated with healthy diet score in all cohorts, and with the overall DQS only in the primarily white Caucasian cohorts. We observed robust correlations between: 1) proline betaine-citrus foods; 2) 3-methylhistidine-red meat, chicken, and eggs; 3) hippuric acid-fruits and vegetables; 4) trimethylamine N-oxide (TMAO)-seafood, meat, and eggs; and 5) tryptophan betaine-nuts/legumes. CONCLUSIONS: Specific serum metabolites reflect intake of citrus fruit/juice, vegetables, animal foods, and nuts/legumes in pregnant women independent of ethnicity, fasting status, and delays to storage across multiple collection centers. Robust biomarkers of overall diet quality varied by cohort. Proline betaine, 3-methylhistidine, hippuric acid, TMAO, and tryptophan betaine were robust dietary biomarkers for investigations of maternal nutrition in diverse populations.

Fine-tuning of Genome-Wide Polygenic Risk Scores and Prediction of Gestational Diabetes in South Asian Women.

Gestational diabetes Mellitus (GDM) affects 1 in 7 births and is associated with numerous adverse health outcomes for both mother and child. GDM is suspected to share a large common genetic background with type 2 diabetes (T2D). The aim of our study was to characterize different GDM polygenic risk scores (PRSs) and test their association with GDM using data from the South Asian Birth Cohort (START). PRSs were derived for 832 South Asian women from START using the pruning and thresholding (P + T), LDpred, and GraBLD methods. Weights were derived from a multi-ethnic and a white Caucasian study of the DIAGRAM consortium. GDM status was defined using South Asian-specific glucose values in response to an oral glucose tolerance test. Association with GDM was tested using logistic regression. Results were replicated in South Asian women from the UK Biobank (UKB) study. The top ranking P + T, LDpred and GraBLD PRSs were all based on DIAGRAM's multi-ethnic study. The best PRS was highly associated with GDM in START (AUC = 0.62, OR = 1.60 [95% CI = 1.44-1.69]), and in South Asian women from UKB (AUC = 0.65, OR = 1.69 [95% CI = 1.28-2.24]). Our results highlight the importance of combining genome-wide genotypes and summary statistics from large multi-ethnic studies to optimize PRSs in South Asians.

Validity and Reproducibility of a Semi-Quantitative Food-Frequency Questionnaire Designed to Measure the Nutrient Intakes of Canadian South Asian Infants at 12 Months of Age.

Purpose: Validated methods to assess diet of non-European infants are sparse. We assessed the validity and reliability of a semi-quantitative food-frequency questionnaire (FFQ) for South Asian infants in Canada.Methods: We developed an 80-item FFQ to assess infant nutrient intake in the South Asian Birth Cohort study (START). Caregivers completed the FFQ twice along with two 24-hour diet recalls. We measured infant plasma ferritin to cross-validate reported iron intake. We evaluated validity using Spearman's rho (ρ), and reliability using the intraclass correlation coefficient.Results: Seventy-six caregivers provided 2 FFQs and 2 24-hour diet recalls. Energy-adjusted, de-attenuated correlations between the FFQs and 24-hour diet recalls ranged from -0.29 (monounsaturated fat) through 1.00 (cholesterol). The FFQ overestimated energy intake by 128%. Iron intake by 24-hour diet recalls correlated with plasma ferritin (r = 0.41; P = 0.01; n = 37), but iron intake by FFQ did not. The average reproducibility coefficient of the FFQ ranged from 0.24 (macronutrients) to 0.65 (minerals).Conclusions: Among South Asian infants living in Canada, at least 2 days of diet recall completed with the primary caregiver yields more valid and reproducible estimates of nutrient intakes than a semi-quantitative FFQ, and it highlights that careful selection of FFQ portion sizes is important for assessing dietary intake with an FFQ.

Ethnic differences in maternal diet in pregnancy and infant eczema.

BACKGROUND: The global prevalence of childhood eczema has increased over the last few decades, with a marked increase in high-income countries. Differences in prevalence of childhood eczema between countries and ethnicities suggest that genetic and early modifiable environmental factors, such as dietary intake, may underlie this observation. To investigate the association between pregnancy diet and infant eczema in a consortium of prospective Canadian birth cohorts predominantly comprised of white Europeans and South Asians. METHODS: We evaluated the association of maternal dietary patterns reported during pregnancy (assessed at 24-28 weeks gestation using a semi-quantitiative food-frequency questionnaire) with parent-reported physician-diagnosed infant eczema at 1-year from 2,160 mother-infant pairs. Using three dietary patterns ("Western", "plant-based", and "Balanced") previously derived in this cohort using principal component analysis, we used multivariable logistic regression to determine the association of these dietary patterns with infant eczema, adjusted for potential confounders. RESULTS: We observed a lower odds of eczema in the full sample combining white Europeans and South Asians with greater adherence to a plant-based (OR = 0.65; 95% CI: 0.55, 0.76; <0.001) and Western dietary pattern (OR = 0.73; 95% CI: 0.60, 0.89; P<0.01), after adjusting for other known predictors of eczema, including ethnicity, which was not significant. No associations were observed for the balanced diet. An interaction between the Western diet and ethnicity was observed (P<0.001). Following stratification by ethnicity, a protective association between the plant-based diet and infant eczema was confirmed in both white Europeans (OR = 0.59; 95% CI: 0.47, 0.74; P<0.001) and South Asians (OR = 0.77; 95% CI: 0.61, 0.97; P = 0.025). In white Europeans only, a Western diet was associated with a lower odds of infant eczema (OR = 0.69; 95% CI: 0.56, 0.87; P = 0.001) while a balanced diet increased the odds of infant eczema (OR = 1.23; 95% CI: 1.02, 1.49; P = 0.03). Beyond a plant-based diet, no significant associations with other dietary patterns were observed in South Asians. CONCLUSION: A plant-based diet during pregnancy is associated with a lowered odds of infant eczema at 1 year in all participants. Future studies of the components of plant-based diet which underlie the lower risk of eczema are needed.

Hypertension Canada's 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children.

Hypertension Canada's 2020 guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children provide comprehensive, evidence-based guidance for health care professionals and patients. Hypertension Canada develops the guidelines using rigourous methodology, carefully mitigating the risk of bias in our process. All draft recommendations undergo critical review by expert methodologists without conflict to ensure quality. Our guideline panel is diverse, including multiple health professional groups (nurses, pharmacy, academics, and physicians), and worked in concert with experts in primary care and implementation to ensure optimal usability. The 2020 guidelines include new guidance on the management of resistant hypertension and the management of hypertension in women planning pregnancy.

A qualitative investigation of optimal perinatal health: the perspectives of south Asian grandmothers living in southern Ontario, Canada.

BACKGROUND: Perinatal health-seeking behaviours are influenced by various factors, including personal beliefs. South Asian women, who often live within a wide kinship system, can be influenced by the advice and guidance of their mothers and/or mothers-in-law. METHODS: To explore the cultural health perceptions of South Asian grandmothers within this context, we used constructivist grounded theory to sample and interview 17 South Asian grandmothers who reside in Southern Ontario, Canada. Interviews were audio-recorded, transcribed verbatim, and coded/analyzed by three independent coders. RESULTS: Many grandmothers emphasized that the preconception phase should focus on building healthy habits around nutrition, physical activity, and mental wellness; the pregnancy period should encompass an enriched environment (positive relationships, healthy routines, nutritional enhancement); and the postpartum phase should emphasize healing and restoration for both the mother and newborn (self-care, bonding, rebuilding healthy habits). Many of the grandmothers conceptualized these stages as a cyclical relationship where healing and restoration transitions gradually to re-establishing healthy habits before having a subsequent child. They also expressed responsibility in supporting their daughters and/or daughters-in-law with their family units and encouraging the transfer of perinatal health information. CONCLUSIONS: South Asian grandmothers are involved in supporting the family units of their children and involving them in perinatal health programming can be an effective way to translate health knowledge to South Asian women. Video abstract. In order to impact a broad, diverse audience of community members, we collaborated with a South Asian film-maker to distil the research findings, write an impactful script, and produce a short digital story based on the research findings. Currently available on social media (https://www.youtube.com/watch?v=tjcNUVOwatU), the film was celebrated with a CIHR Institute for Human Development, Child and Youth Health Video Talks Prize in 2016.