Association of Lipids, Lipoproteins, and Apolipoproteins with Stroke Subtypes in an International Case Control Study (INTERSTROKE) / 대한뇌졸중학회지

Background@#and Purpose The association of dyslipidemia with stroke has been inconsistent, which may be due to differing associations within etiological stroke subtypes. We sought to determine the association of lipoproteins and apolipoproteins within stroke subtypes. @*Methods@#Standardized incident case-control STROKE study in 32 countries. Cases were patients with acute hospitalized first stroke, and matched by age, sex and site to controls. Concentrations of total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein A1 (apoA1), and apoB were measured. Non-HDL-C was calculated. We estimated multivariable odds ratio (OR) and population attributable risk percentage (PAR%). Outcome measures were all stroke, ischemic stroke (and subtypes), and intracerebral hemorrhage (ICH). @*Results@#Our analysis included 11,898 matched case-control pairs; 77.3% with ischemic stroke and 22.7% with ICH. Increasing apoB (OR, 1.10; 95% confidence interval [CI], 1.06 to 1.14 per standard deviation [SD]) and LDL-C (OR, 1.06; 95% CI, 1.02 to 1.10 per SD) were associated with an increase in risk of ischemic stroke, but a reduced risk of ICH. Increased apoB was significantly associated with large vessel stroke (PAR 13.4%; 95% CI, 5.6 to 28.4) and stroke of undetermined cause. Higher HDL-C (OR, 0.75; 95% CI, 0.72 to 0.78 per SD) and apoA1 (OR, 0.63; 95% CI, 0.61 to 0.66 per SD) were associated with ischemic stroke (and subtypes). While increasing HDL-C was associated with an increased risk of ICH (OR, 1.20; 95% CI, 1.14 to 1.27 per SD), apoA1 was associated with a reduced risk (OR, 0.80; 95% CI, 0.75 to 0.85 per SD). ApoB/A1 (OR, 1.38; 95% CI, 1.32 to 1.44 per SD) had a stronger magnitude of association than the ratio of LDL-C/HDL-C (OR, 1.26; 95% CI, 1.21 to 1.31 per SD) with ischemic stroke (P<0.0001). @*Conclusions@#The pattern and magnitude of association of lipoproteins and apolipoproteins with stroke varies by etiological stroke subtype. While the directions of association for LDL, HDL, and apoB were opposing for ischemic stroke and ICH, apoA1 was associated with a reduction in both ischemic stroke and ICH. The ratio of apoB/A1 was the best lipid predictor of ischemic stroke risk.

Skeletonized vs Pedicled Internal Mammary Artery Graft Harvesting in Coronary Artery Bypass Surgery: A Post Hoc Analysis From the COMPASS Trial.

Importance: The relative safety and patency of skeletonized vs pedicled internal mammary artery grafts in patients undergoing coronary artery bypass graft (CABG) surgery are unknown. Objective: To investigate the association of skeletonized vs pedicled harvesting with internal mammary artery graft patency and clinical outcomes 1 year after CABG surgery. Design, Setting, and Participants: This study was a post hoc analysis of the multicenter, randomized, double-blind, placebo-controlled Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) clinical trial, which enrolled 27 395 patients from 602 centers in 33 countries from March 2013 through May 2016. Eligibility criteria for the trial included CABG surgery for coronary artery disease with at least 2 grafts implanted and an estimated glomerular filtration rate of at least 30 mL/min. A total of 1002 of 1448 patients were randomized to the CABG arm of the COMPASS trial and underwent skeletonized (282 [28.1%]) or pedicled (720 [71.9%]) internal mammary artery harvesting. The patients had evaluable angiography results 1 year after surgery. Data were analyzed from October 11, 2019, to May 14, 2020. Interventions: Patients underwent graft harvesting with either the pedicled technique or skeletonized technique. Main Outcomes and Measures: The primary outcome was graft occlusion 1 year after CABG surgery, as assessed by computed tomography angiography. Results: A total of 1002 patients underwent skeletonized (282 [28.1%]; mean [SD] age, 65.9 [8.1] years; 229 men [81.2%]; 194 White patients [68.8%]) or pedicled (720 [71.9%]; mean [SD] age, 64.8 [7.6] years; 603 men [83.8%]; 455 White patients [63.2%]) internal mammary artery harvesting. Rates of internal mammary artery graft occlusion 1 year after CABG surgery were higher in the skeletonized group than in the pedicled group (33 of 344 [9.6%] vs 30 of 764 [3.9%]; graft-level adjusted odds ratio, 2.41; 95% CI, 1.39-4.20; P = .002), including the left internal mammary artery to left anterior descending artery (21 of 289 [7.3%] vs 25 of 725 [3.4%]; graft-level adjusted odds ratio, 2.10; 95% CI, 1.14-3.88, P = .02). After a mean follow-up of 23 months, skeletonized graft harvesting was also associated with a higher rate of major adverse cardiovascular events (20 [7.1%] vs 15 [2.1%]; adjusted hazard ratio, 3.19; 95% CI, 1.53-6.67; P = .002) and repeated revascularization (14 [5.0%] vs 10 [1.4%]; adjusted hazard ratio, 2.75; 95% CI, 1.10-6.88; P = .03). Conclusions and Relevance: This post hoc analysis of the COMPASS randomized clinical trial found that harvesting of the internal mammary artery during CABG surgery using a skeletonized technique was associated with a higher rate of graft occlusion and worse clinical outcomes than the traditional pedicled technique. Future randomized clinical trials are needed to establish the safety and patency of the skeletonized technique. Trial Registration: ClinicalTrials.gov Identifier: NCT01776424.

COVID-19 Vaccination Prioritization Based on Cardiovascular Risk Factors and Number-Needed-to-Vaccinate to Prevent Death

The supply limitations of COVID-19 vaccines have led to the need to prioritize vaccine distribution. Obesity, diabetes and hypertension have been associated with an increased risk of severe COVID-19 infection. Approximately half as many individuals with a cardiovascular risk factor need to be vaccinated against COVID-19 to prevent related death as compared with individuals without a risk factor. Our analysis suggests that prioritizing adults with these cardiovascular risk factors for vaccination is likely to be an efficient way to reduce population COVID-19 mortality.

Correction to: Determinants of exclusive breastfeeding in infants of six months and below in Malawi: a cross sectional study.

An amendment to this paper has been published and can be accessed via the original article.

Determinants of exclusive breastfeeding in infants of six months and below in Malawi: a cross sectional study.

BACKGROUND: UNICEF and WHO recommend that all children should be exclusively breastfed for the first 6 months of life as breastmilk contains all the nutrients an infant needs during this period. In Malawi, exclusive breastfeeding has been declining from 72% (2009), 70.2% (2014) and 61% in the most recent survey (2015-16). We aimed to determine factors associated with exclusive breastfeeding in Malawi. METHODS: We used data from the Malawi Demographic and Health Survey (MDHS) 2015-2016. Survey records for 2059 mothers of children aged 6 months and below were identified and potential factors influencing infant feeding were examined. Logistic regression analysis was carried out to model determinants of exclusive breastfeeding (EBF). RESULTS: EBF declined in proportion to the age of the infant. Significant associations with continuing EBF were age of the mother, ethnicity of the mother, sex of infant and number of siblings. Members of the Tumbuka (OR = 1.71, CI. 1.13-2.59) and Ngoni (OR = 2.05, CI. 1.38-3.05) communities were more likely to practice EBF. In addition, mothers with female babies (OR = 1.35, CI. 1.08-1.70) and those with 3-4 children (OR = 1.47, CI. 1.04-2.08) were more likely to engage in EBF. CONCLUSION: We identify important variations in EBF practices among population sub-groups in Malawi that need to be considered when framing health education messaging. Work is needed to assess the impact of more targeted messaging, whether delivered via 'ten steps' to successful breastfeeding under Baby Friendly Hospital Initiative (BFHI) programming or other health education and awareness campaigns to sensitize communities on implications of some cultural practices on the lives of babies. The potential role for mass media, targeted Health Surveillance Assistants' (HSA) home visits and male involvement also require exploration.

Influence of dietary patterns on the risk of acute myocardial infarction in China population: the INTERHEART China study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Some dietary patterns are risk factors for acute myocardial infarction (AMI). Chinese traditional food and habits vary from other cultures. The present study determined whether different dietary patterns were associated with AMI in Chinese people.</p><p><b>METHODS</b>We conducted a case-control study. There were 1312 cases of first AMI and 2235 control subjects who did not have previous angina, diabetes mellitus, hypertension or stroke. Controls were matched to cases on age and gender. Diet was measured with a validated, 19 item food frequency questionnaire. We identified three major dietary patterns using factor analysis: vitamin and microelement pattern (high intake of vegetables, fruits and tofu), carbohydrate pattern (high in grain), and fat and protein pattern (high in meat, fish, eggs and fried foods).</p><p><b>RESULTS</b>After adjusting for all risk factors, the vitamin and microelement pattern was inversely associated with AMI risk (global P value, 0.0001). Compared with the first quartile, the adjusted ORs of AMI were 0.81 (95%CI: 0.66 - 1.00) for the second quartile, 0.67 (95%CI: 0.54 - 0.82) for the third, and 0.70 (95%CI: 0.56 - 0.88) for the fourth. Several dietary frequencies (serves per week) including vegetables, fruits and tofu were closely associated with decrease of AMI risk. Carbohydrate pattern showed weak relationship with AMI. We observed a U-shaped association between frequencies of fat and protein pattern and AMI risk. Excessive fat intake increased the AMI risk. The adjusted OR of AMI associated with the higher level of green vegetables was 0.37 (95%CI: 0.24 - 0.57) in women and 0.65 (95%CI: 0.51 - 0.82) in men (P value for heterogeneity, 0.0140).</p><p><b>CONCLUSIONS</b>Unhealthy dietary intake can increase the AMI risk. Improving intake of vegetables, fruits and tofu have the potential to partially prevent the rising epidemic of cardiovascular disease in China.</p>

Influence of socioeconomic status on acute myocardial infarction in the Chinese population: the INTERHEART China study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Many researches report that low socioeconomic status (SES) is associated with a higher risk of coronary heart disease (CHD). This study aimed to determine whether levels of education, family income, and other SES were associated with acute myocardial infarction (AMI) in the Chinese population, and to compare the difference in this association between northern and southern regions in China.</p><p><b>METHODS</b>We conducted a case-control study. Cases were first AMI (n = 2909). Controls (n = 2947) were randomly selected and frequency matched to cases on age and sex. SES was measured using education, family income, possessions in the household, and occupation.</p><p><b>RESULTS</b>Low levels of education (8 years) were more common in cases compared to controls (53.4% and 44.1%; P = 0.0001). After adjusting all risk factors, the level of education was associated with AMI risk in the Chinese population (P = 0.0005). The odds ratio (OR) associated with education of 8 years or less, compared with more than 12 years (trade school/college/university) was 1.33 (95%CI 1.12 - 1.59), and for education of 9 - 12 years 1.04 (95%CI 0.88 - 1.33). The proportion of higher income population was more in controls than cases (39.4% and 35.3%). Number of possessions and non-professional occupation were only weakly or not at all independently related to AMI. The adjusted OR associated with the lower education was 2.38 (95%CI 1.67 - 3.39) in women, and 1.18 (95%CI 0.99 - 1.42) in men (P = 0.0001, for heterogeneity). The interaction between levels of education and different regions was significant (P = 0.0206, for interaction).</p><p><b>CONCLUSION</b>Several socioeconomic factors including levels of education and income were closely associated with increase of AMI risk in China, most markedly in northeast and southern area. The effect of education was stronger towards AMI in women than men.</p>

Association of psychological risk factors and acute myocardial infarction in China: the INTER-HEART China study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Most data about psychological factors relating to acute myocardial infarction (AMI) were obtained from studies carried out in western countries. Results from small descriptive cross-sectional studies in China were inconclusive. The aim of this study was to explore possible associations between psychological risk factors and AMI among the Chinese population with a large-scale case-control study.</p><p><b>METHODS</b>This study was part of the INTER-HEART China study, itself part of the large international INTER-HEART study of cardiovascular risk factors. In this case-control study, 2909 cases and 2947 controls were recruited from 17 cities. Psychological stress, negative life events, depression and controllability of life circumstances were assessed.</p><p><b>RESULTS</b>Cases reported more psychological stress at home or work and odds ratios (ORs) were 3.2 (95%CI 2.1 - 4.9) for permanent stress and 2.1 (95%CI 1.5 - 2.8) for several periods of stress respectively. More cases experienced depression compared with controls (19.6% vs. 9.3%) and ORs were 2.2 (95%CI 1.9 - 2.6). Subjects with 1, 2 and 3 or more depressive symptoms had increased risk of AMI by 2.1, 2.2 and 2.6 fold, respectively, i.e., more depressive symptoms were associated with higher risks of AMI (P for trend < 0.0001). Women had a greater risk of AMI from depression (OR 3.0, 95%CI 2.2 - 4.0) compared to men (OR 2.0, 95%CI 1.6 - 2.4), P for interaction = 0.0364. Negative life events in subjects were associated with increased risk of AMI, OR 1.7 (95%CI 1.4 - 2.0) for one event and 1.8 (95%CI 1.3 - 2.4) for two or more events. High levels of controllability of life circumstances reduced the risk for AMI (OR 0.8, 95%CI 0.7 - 1.0).</p><p><b>CONCLUSIONS</b>Several psychological factors were closely associated with increased AMI risk among Chinese population. Psychological stress had a greater AMI risk in men but depression was more significant among women.</p>

[Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries in a case-control study based on the INTERHEART study]. / A módosítható kockázati tényezok hatása a szívizominfarktus kialakulására 52 országra kiterjedo eset-kontroll vizsgálat az INTERHEART tanulmány alapján.

An international, standardised case-control study was established to assess the importance of risk factors for coronary heart disease worldwide. From 52 countries representing every inhabited continent 15152 cases and 14820 controls were enrolled. The relation of smoking, history of hypertension and/or diabetes, waist/hip ratio, dietary patterns, physical activity, consumption of alcohol, blood apolipoproteins and psychosocial factors to myocardial infarction was reported. Odds ratios and their 99% confidence limits for the association of risk factors to acute myocardial infarction and their population attributable risks were calculated. Smoking (odds ratio 2.87 for current vs never, population attributable risk 35.7% for current and former smoker vs never), raised apolipoprotein B / apolipoprotein A1 ratio (3.25 for top vs lowest quintile, population attributable risk 49.2 for top four quintiles vs lowest quintile), history of hypertension (1.91, 17.9%), diabetes (2.37, 9.9%), abdominal obesity (1.12 for top vs lowest tertile and 1.62 for middle vs lowest tertile, 20.1% for top two tertiles vs lowest tertile), psychosocial factors (2.67, 32.5), daily consumption of fruits and vegetables (0.70, 13.7% for lack of daily consumption), regular alcohol consumption (0.91, 6.7%), and regular physical activity (0.86, 12.2%) were all significantly related to acute myocardial infarction (p < 0.0001 for all risk factors, and p = 0.03 for alcohol). These associations were noted in men and women, old and young and in all regions of the world. Collectively these nine risk factors accounted for 90% of the population attributable risk in men and 94% in women. This finding suggests that approaches to prevention can be based on similar principles worldwide.