Intermittent fasting for the prevention of cardiovascular disease.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death worldwide. Lifestyle changes are at the forefront of preventing the disease. This includes advice such as increasing physical activity and having a healthy balanced diet to reduce risk factors. Intermittent fasting (IF) is a popular dietary plan involving restricting caloric intake to certain days in the week such as alternate day fasting and periodic fasting, and restricting intake to a number of hours in a given day, otherwise known as time-restricted feeding. IF is being researched for its benefits and many randomised controlled trials have looked at its benefits in preventing CVD. OBJECTIVES: To determine the role of IF in preventing and reducing the risk of CVD in people with or without prior documented CVD. SEARCH METHODS: We conducted our search on 12 December 2019; we searched CENTRAL, MEDLINE and Embase. We also searched three trials registers and searched the reference lists of included papers. Systematic reviews were also viewed for additional studies. There was no language restriction applied. SELECTION CRITERIA: We included randomised controlled trials comparing IF to ad libitum feeding (eating at any time with no specific caloric restriction) or continuous energy restriction (CER). Participants had to be over the age of 18 and included those with and without cardiometabolic risk factors. Intermittent fasting was categorised into alternate-day fasting, modified alternate-day fasting, periodic fasting and time-restricted feeding. DATA COLLECTION AND ANALYSIS: Five review authors independently selected studies for inclusion and extraction. Primary outcomes included all-cause mortality, cardiovascular mortality, stroke, myocardial infarction, and heart failure. Secondary outcomes include the absolute change in body weight, and glucose. Furthermore, side effects such as headaches and changes to the quality of life were also noted. For continuous data, pooled mean differences (MD) (with 95% confidence intervals (CIs)) were calculated. We contacted trial authors to obtain missing data. We used GRADE to assess the certainty of the evidence.  MAIN RESULTS: Our search yielded 39,165 records after the removal of duplicates. From this, 26 studies met our criteria, and 18 were included in the pooled analysis. The 18 studies included 1125 participants and observed outcomes ranging from four weeks to six months. No studies included data on all-cause mortality, cardiovascular mortality, stroke, myocardial infarction, and heart failure at any point during follow-up. Of quantitatively analysed data, seven studies compared IF with ab libitum feeding, eight studies compared IF with CER, and three studies compared IF with both ad libitum feeding and CER. Outcomes were reported at short term (≤ 3 months) and medium term (> 3 months to 12 months) follow-up. Body weight was reduced with IF compared to ad libitum feeding in the short term (MD -2.88 kg, 95% CI -3.96 to -1.80; 224 participants; 7 studies; low-certainty evidence). We are uncertain of the effect of IF when compared to CER in the short term (MD -0.88 kg, 95% CI -1.76 to 0.00; 719 participants; 10 studies; very low-certainty evidence) and there may be no effect in the medium term (MD -0.56 kg, 95% CI -1.68 to 0.56; 279 participants; 4 studies; low-certainty evidence). We are uncertain about the effect of IF on glucose when compared to ad libitum feeding in the short term (MD -0.03 mmol/L, 95% CI -0.26 to 0.19; 95 participants; 3 studies; very-low-certainty of evidence) and when compared to CER  in the short term: MD -0.02 mmol/L, 95% CI -0.16 to 0.12; 582 participants; 9 studies; very low-certainty; medium term: MD 0.01, 95% CI -0.10 to 0.11; 279 participants; 4 studies; low-certainty evidence). The changes in body weight and glucose were not deemed to be clinically significant. Four studies reported data on side effects, with some participants complaining of mild headaches. One study reported on the quality of life using the RAND SF-36 score. There was a modest increase in the physical component summary score. AUTHORS' CONCLUSIONS: Intermittent fasting was seen to be superior to ad libitum feeding in reducing weight. However, this was not clinically significant. There was no significant clinical difference between IF and CER in improving cardiometabolic risk factors to reduce the risk of CVD. Further research is needed to understand the safety and risk-benefit analysis of IF in specific patient groups (e.g. patients with diabetes or eating disorders) as well as the effect on longer-term outcomes such as all-cause mortality and myocardial infarction.

The ticking time bomb in lifestyle-related diseases among women in the Gulf Cooperation Council countries; review of systematic reviews.

BACKGROUND: This study aims to review all published systematic reviews on the prevalence of modifiable cardiovascular disease risk factors among women from the Gulf Cooperation Council countries (GCC). This is the first review of other systematic reviews that concentrates on lifestyle related diseases among women in GCC countries only. METHOD: Literature searches were carried out in three electronic databases for all published systematic reviews on the prevalence of cardiovascular disease risk factors in the GCC countries between January 2000 and February 2016. RESULTS: Eleven systematic reviews were identified and selected for our review. Common reported risk factors for cardiovascular disease were obesity, physical inactivity, diabetes, metabolic syndrome and hypertension. In GCC countries, obesity among the female population ranges from 29 to 45.7%, which is one of the highest rates globally, and it is linked with physical inactivity, ranging from 45 to 98.7%. The prevalence of diabetes is listed as one of the top ten factors globally, and was reported with an average of 21%. Hypertension ranged from 20.9 to 53%. CONCLUSIONS: The high prevalence of lifestyle-related diseases among women population in GCC is a ticking time bomb and is reaching alarming levels, and require a fundamental social and political changes. These findings highlight the need for comprehensive work among the GCC to strengthen the regulatory framework to decrease and control the prevalence of these factors.

Hypertensive Subjects are More Likely to Develop Coronary Artery Lesions: A Study by Computerised Tomography Coronary Angiography.

Coronary Computed Tomography Angiography (CCTA) is commonly used to identify coronary artery disease. In this study, the indications for CCTA referrals are reviewed, to identify the strongest predictors of CAD, as seen on CCTA. A retrospective study, reviewing the electronic health records of consecutive patients who underwent CCTA between July and November 2020 at our Trust, was conducted. A total of 485 patient reports were reviewed. Of patients with moderate-to-severe CAD, 128 (73.6%) were hypertensive. Of those with severe CAD, 79 patients (76%) were hypertensive. Univariate analysis for comparison of patients with absent (n = 219), mild (n = 92), moderate (n = 70) and severe (n = 104) CAD revealed that hypertension (P < .001), diabetes mellitus (P < .001), gender (P < .001), dyslipidemia (P < .001) and smoking (P = .006), were each significantly associated with the presence of CAD on CCTA. However, multiple logistic regression analysis confirmed that hypertension has the strongest association with CAD (OR = 2.22, P < .001) Furthermore, the presence of typical chest pain in hypertensive patients was strongly associated with significant CAD, on CCTA. Among all risk factors, hypertension is the strongest independent predictor for the presence of CAD on CCTA. These results suggest that hypertension is a significant factor when considering referral for CCTA, particularly when associated with chest pain.

Hydatid Cyst of the Heart.

Cystic hydatid disease is responsible for the loss of 1 to 3 million disability-adjusted life years every year. Infestation of the heart, though rare, can result in serious complications if left untreated. We retrospectively collected information on 19 patients with cardiac hydatid cyst admitted at the Center for Cardiac Surgery of Ibn Al-Bitar Hospital in Baghdad from July 2007 to July 2011 who were either in need of a cardiac surgery for treating hydatid cysts or presented with emergency conditions. Nine (47%) patients presented with left-sided heart failure and mitral valve dysfunction, 5 (26%) patients had hydatid cysts in the pericardium, 3 (16%) patients had hydatid cyst in the right ventricle and presented with right-sided heart failure, and 2 (11%) patients who presented with cardiac arrhythmias had infestation in the interventricular septum. Removal of cysts following open-heart surgery was successful and was followed by the use of mebendazole or albendazole for 5 years. We conclude that cardiac hydatid cyst that leads to various cardiac symptoms can be successfully managed and should be considered as a diagnostic possibility in patients with cardiac symptoms in endemic areas.

Is glycated haemoglobin a sensitive index to identify left ventricular dysfunction two months after acute myocardial infarction in normotensive subjects?

BACKGROUND: Glycated haemoglobin concentration (HbA1c) is a marker of glucose metabolism. Glucose intolerance is associated with a high incidence of left ventricular (LV) dysfunction after acute myocardial infarction (AMI). This study was carried out in order to relate HbA1c to LV function two months following AMI in 171 normotensive patients who were not previously known to have had diabetes mellitus. METHODS: Oral glucose tolerance test (GTT) and HbA1c. Echo and Doppler-cardiography were used to measure the E/A (peak velocity of the early filling/atrial contraction waves) at rest and at peak isometric exercise (IME), deceleration time (DT) of E wave, LV ejection fraction (LVEF), LV mass index and diastolic LV function. RESULTS: GTT was diabetic in 20, impaired in 35 and normal in 116 subjects. HbA1c was >6.0% (cut off level for high risk subjects) in 76 patients (67%) with impaired relaxation (E/A<1) during IME and in 30 patients (27%) with restrictive LV filling (identified by E/A=1-2, DT<140 ms). The sensitivity and specificity of HbA1c to predict underlying impaired LV relaxation were 68% and 37%, respectively, and to predict restrictive LV filling were 27% and 98%, respectively. Whereas in univariate analysis, DT.3 was linearly related to HbA1c only (p=0.0002), multiple regression analysis showed that HbA1c was related to LVEF, DT and E/A but not to LVH, LVMI, smoking habit, age, gender and creatinine kinase level during admission for AMI. CONCLUSION: At 2 months after admission for AMI, HbA1c is related to systolic and diastolic LV function but not to LVMI or LVH. HbA1c is a sensitive predictor of impaired relaxation but highly specific to rule out underlying non-restrictive LV filling.

Left ventricular diastolic function in normotensive subjects 2 months after acute myocardial infarction is related to glucose intolerance.

BACKGROUND: Both glucose intolerance and myocardial infarction are independently associated with impaired left ventricular (LV) function. This study was carried out to relate LV diastolic function in normotensive subjects 2 months after acute myocardial infarction (AMI) to glucose tolerance status. METHODS: Left ventricular ejection fraction (LVEF), LV mass index, peak velocity of the early phase/atrial contraction wave, deceleration time of E wave, and isovolumic relaxation time were measured during echocardiograph/Doppler cardiography in 200 normotensive patients 2 months after AMI. Twenty-nine patients were known to be diabetic on admission with AMI. Glucose tolerance test was carried out in the 171 patients who are not known to be diabetic. RESULTS: Independent of LVEF, restrictive LV filling (peak velocity of the early phase/atrial contraction wave > 1 but < 2 associated with deceleration time of E wave < or = 140 milliseconds) was found in 72% of the known-diabetic patients, 70% of the 20 preclinical diabetic patients, 23% of the 35 patients with impaired glucose tolerance, 13% of the 15 patients with stress hyperglycemia, and 7% of the euglycemic patients (P < .01). In the rest of these patients, LV filling was nonrestrictive. No significant difference was observed in LVEF and LV mass index between patient groups. CONCLUSION: Independent of LVEF, the pattern of abnormal LV filling in normotensive subjects 2 months after AMI is a function of the severity of glucose intolerance, restrictive in the majority of the diabetic patients and nonrestrictive in the majority of the euglycemic patients, impaired glucose tolerance, and stress hyperglycemia. After AMI, abnormal LV filling occurs even in the absence of detectable systolic dysfunction or left ventricular hypertrophy.

Combination of site of infarct, unrecognized glucose intolerance, and reinfarction after acute myocardial infarction in normotensive subjects is determinant of the development of subsequent systemic hypertension: a pilot study.

BACKGROUND: The natural history of hypertension in healthy normotensive subjects has been described in the Framingham population. We aim to study the rate of progression to hypertension in normotensive subjects after acute myocardial infarction (AMI). METHODS: One hundred seventy-three consecutive normotensive subjects admitted to the Coronary Care Unit with AMI were studied retrospectively with prospective follow-up 4 years after AMI. All the patients who were not known to be diabetic on admission (n = 150) underwent glucose tolerance test (GTT) at 2 months after AMI. RESULTS: Among the 15 patients (8.7%) who developed hypertension, GTT was abnormal in 75% (diabetes = 3, impaired glucose tolerance = 9). There were significantly more Indo-Asians and fewer whites in the hypertensive than in the normotesive patients but they were similar in age and gender, creatinine kinase level, and rate of thrombolysis during admission for AMI. Multiple regression analysis showed that progression to hypertension was a function of the presence of anterior AMI on admission (P = .0297), abnormal GTT (P = .0156), and subsequent MI on follow-up (P = .0122), but was independent of age, gender, smoking habit, body weight, previous MI, thrombolysis, creatinine kinase level, subsequent development of heart failure, and intake of beta-adrenergic blockade or angiotensin-converting enzyme (ACE) inhibitor. Of the hypertensive patients, 47% (n = 7) died compared to 8% (n = 13) of the normotensive subjects (P < .0001). CONCLUSIONS: Progression to hypertension in normotensive subjects after AMI is determined by a combination of the site of the infarct, GTT 2 months after AMI, and subsequent development of a second MI. Systemic hypertension after AMI is associated with a high mortality.

Left ventricular hypertrophy and preclinical impaired glucose tolerance and diabetes mellitus contribute to abnormal left ventricular diastolic function in hypertensive patients.

BACKGROUND: Impaired left ventricular diastolic function is not uncommon in patients with either diabetes mellitus or hypertension. This study was carried out to assess the contribution of left ventricular hypertrophy, high blood pressure, preclinical impaired glucose tolerance and diabetes mellitus to left ventricular diastolic function in patients attending a hypertension clinic. METHODS: Echocardiography, 24-h ambulatory blood pressure monitoring and oral glucose tolerance tests were carried out in 152 consecutive hypertensive patients who had no evidence of ischaemic heart disease and were not known to be diabetic. From echocardiography, E/A (peak velocity of early/atrial filling waves of the transmitral flow) at rest and at peak standardized isometric exercise using handgrip, left ventricular mass index and deceleration time of the E wave were derived. RESULTS: Patients with impaired glucose tolerance and diabetes mellitus had lower E/A than the euglycaemic subjects both at rest (P=0.0073) and during isometric exercise (P<0.0001). E/A significantly reduced during isometric exercise in patients with impaired glucose tolerance and diabetes but not in euglycaemic patients. Deceleration time was shortened with a worsening degree of glucose intolerance in all the patients (P=0.0005), in those with left ventricular hypertrophy (P=0.0006) and in those without left ventricular hypertrophy (P=0.033). When adjusted for age, gender, race, body mass index, smoking history, ambulatory blood pressure findings, cholesterol and triglyceride levels and antihypertensive medications taken, E/A at isometric exercise was related to results of glucose tolerance tests and was inversely proportional to left ventricular mass index (P<0.0001). No significant differences were found whether patients were taking antihypertensive medications or not. CONCLUSION: In hypertensive patients, left ventricular diastolic function is determined by left ventricular mass index and the status of preclinical glucose intolerance, independent of age, gender, race, body mass index, blood pressure level, nocturnal drop in blood pressure or lipid level. These findings were not prejudiced by antihypertensive medications.

The glucose tolerance test, but not HbA(1c), remains the gold standard in identifying unrecognized diabetes mellitus and impaired glucose tolerance in hypertensive subjects.

The objective of this study was to compare the value of the oral glucose tolerance test (GTT), glycated hemoglobin concentration (HbA(1c)), and fasting plasma glucose (FPG) for identifying unrecognized diabetes mellitus (DM) and impaired glucose tolerance (IGT) in hypertensive subjects. One hundred forty-four consecutive subjects who were not known to have DM and who were attending the Hypertension Clinic underwent 24-hour ambulatory blood pressure (BP) monitoring. A GTT and an HbA(1c) measurement were also carried out. Abnormal results from GTT were found in 94 patients (65%). Results from FPG were not different between those with DM and IGT but were significantly higher than in the euglycemic subjects. The FPG was between 110-125 mg/dL (6.1-6.9 mmol/L) in 31% (n = 20) of patients with IGT and in 53% (n = 16) of those with DM. With use of the previously published criteria to diagnose DM of FPG > or = 103 mg/dL (5.7 mmol/L) and HbA(1c) > or = 5.9%, 33% of our diabetic subjects and 75% of those with IGT would have been misclassified as euglycemic. The previously reported cut-off point for HbA(1c) of >6.1% to diagnose DM was present in 77% of our patients with DM and in 14% (n = 9) of the patients with IGT. Multiple regression analysis showed that an abnormal result from GTT was independent of the level of clinical or ambulatory BP, nocturnal BP dip, cholesterol level, smoking history, race, or class of antihypertensive medication taken. FPG levels or HbA(1c), or their combination, are not accurate enough to identify DM or IGT in patients attending a hospital Hypertension Clinic. A GTT may be required in these patients to reliably identify those with DM or IGT.

Sphygmomanometer cuffs: a potential source of infection!

We evaluated the potential pathogenic hazard of sphygmomanometer blood pressure cuffs (BPCs) in a hospital setting. Prospectively, the presence of bacterial organisms on 120 BPCs in 14 medical wards and outpatient clinics in a district general hospital in London was assessed. Swabs taken from the inner aspect of the cuffs were cultured using standard microbiological techniques. Bacterial organisms were found in 85% (102) of the 120 BPCs assessed. The highest rates of contamination were found in the outpatients department (90%). There were differences in the most common bacterial species isolated between the samples obtained from the outpatient clinics and the wards, with coagulase-negative Staphylococcus and diphtheroids being the most prevalent species in the wards and outpatient clinics, respectively. These findings highlight the necessity to eliminate this potential risk of infection.

Prevalence of unrecognized abnormal glucose tolerance in patients attending a hospital hypertension clinic.

BACKGROUND: Diabetes mellitus (DM) and impaired glucose tolerance (IGT) are not uncommonly associated with hypertension. Fasting blood glucose level is still recognized as an indicator of DM. METHODS: We studied 99 consecutive patients who were not known to be diabetic patients and with no cardiac history, who were attending our Hypertension Clinic for investigation and management of uncontrolled blood pressure (BP). Oral glucose tolerance test (GTT) was carried out and area under the curve for the GTT (AUC-glucose) was calculated. All patients underwent 24-h ambulatory BP monitoring. RESULTS: The GTT was abnormal in 58 patients (58%), indicating IGT in 18, impaired fasting glucose in 16, and DM in 24. The fasting and 120-min glucose level and AUC-glucose in patients with DM on GTT was higher (P <.0001) than in those with IGT/IFG and in the latter was higher than those with normal GTT. Multiple regression analysis showed that abnormal GTT was independent of the following: level of clinic or ambulatory BP; presence or absence of nocturnal BP dip; cholesterol, sodium, and potassium levels; smoking history; alcohol intake; prior treatment for hypertension; and ethnicity. These results were also independent of antihypertensive medications taken. No significant difference was found in glucose level during GTT, AUC-glucose, or age among the groups of patients receiving diuretics only, those receiving diuretics and beta-blockers, and those not receiving any of these agents. CONCLUSIONS: The prevalence of glucose abnormalities in hypertensive patients attending a hospital hypertension clinic is sufficiently high to warrant screening for DM and IGT, and fasting glucose levels are not accurate enough for this purpose. All patients attending such a clinic should undergo a GTT.

Age-associated changes in left ventricular diastolic function are related to increasing left ventricular mass.

Isometric exercise (IME) produces significant hemodynamic changes in the cardiovascular system. We have used IME to study the effect of age on diastolic left ventricular (LV) function in 100 normal volunteers. The E/A ratio (peak velocity of early/atrial filling phases), deceleration time (DT), and isovolumic relaxation time (IVRT) of the transmitral flow were assessed during echocardiography with pulsed-Doppler ultrasound at rest and at peak IME using handgrip. LV mass index (LVMI) and LV ejection fraction (LVEF) were also calculated. Both E/A and IVRT reduced significantly with increasing age. The LVEF decreased (P <.0001), whereas LVMI increased (P <.05) with advancing age. The LVEF was inversely related to LVMI (P <.05). An inverse relationship was noted between E/A and LVMI (P <.01) during IME. The contribution of the atrial contraction to the total diastolic flow increased significantly with advancing age (P <.02) and increased from 0.29 +/- 0.04 at rest to 0.34 +/- 0.08 during IME (P <.0001). It is concluded that with progressing age, the left ventricle becomes stiffer resulting in a reduction in early filling and a compensatory increase in flow due to atrial contraction. A progressive increase in LVMI, which accompanies aging may contribute to stiffening of the left ventricle and deterioration in diastolic function of the left ventricle. This is exaggerated by IME.

Impaired left ventricular diastolic function during isometric exercise in asymptomatic patients with hyperlipidaemia.

BACKGROUND: Left ventricular (LV) diastolic dysfunction is an early sign, and may be more sensitive indicator, of ischaemic heart disease (IHD) than systolic dysfunction. METHODS: LV diastolic function was assessed during isometric exercise (IME) in 37 consecutive normotensive hyperlipidaemics (LIP), without cardiac history or symptoms. Each patient underwent a stress ECG test and 2-D echo and Doppler cardiography. During the latter, transmitral flow at rest and at peak standardised IME using handgrip was studied. From the tracings, the E/A (peak velocity of the early/atrial components), the contribution of atrial systole to LV filling (ACF), the deceleration time (DT) of the E wave and the isovolumic relaxation time (IVRT) were calculated. Results were compared to 37 age-matched normal healthy volunteers (NOR). RESULTS: Resting E/A was not different between NOR and the LIP. A significant reduction in E/A with IME was observed in LIP but not in NOR. Impaired LV filling (shown by E/A<1) was demonstrated in five patients (13%) at rest and in 20 patients (54%) at peak IME. All NOR had E/A>1 suggesting normal LV filling. Fifteen of the 30 patients with negative stress ECG test demonstrated LV diastolic dysfunction. ACF was higher in LIP than NOR and increased significantly (P<0.005) by 23% during IME. DT and IVRT in LIP were not different from NOR. In neither NOR nor LIP, were the LV diastolic functional parameters related to gender, smoking habit or levels of total cholesterol, LDL- or HDL-cholesterol or triglycerides. CONCLUSION: The prevalence of LV diastolic dysfunction in asymptomatic patients with hyperlipidaemia despite a negative stress ECG test may be evidence of early underlying pre-clinical myocardial ischaemia.

The degree of albuminuria is related to left ventricular hypertrophy in hypertensive diabetics and is associated with abnormal left ventricular filling: a pilot study.

The association of albuminuria and left ventricular (LV) hypertrophy (LVH) in diabetics aggravates the prognosis. The authors studied the relation between LVH and the degree of albuminuria in diabetics and investigated the relationship of albuminuria to LV filling. A comparison was made between 30 hypertensive diabetics, 10 of whom had microalbuminuria (MIC) and 20 had macroalbuminuria (MAC), and 18 diabetics who were normotensive and normalbuminuric (NOR). LV mass index (LVMI) and LV ejection fraction (LVEF) were measured during echocardiography. LV filling pattern at rest and at peak standardized isometric exercise (IME) using handgrip was assessed by measuring E/A (peak velocity of the early/atrial filling waves) of the transmitral flow during Doppler and echocardiography. Each patient underwent a stress ECG test. LVMI was higher in MAC (132.3 +/- 55.4) than in MIC (115.6 +/- 32.5) or NOR (90.0 +/- 31.8) (p<0.01). There were more patients in MAC with LVH (n = 13) and abnormal filling (n = 9 at rest and 16 with IME) than in MIC (LVH = 5, abnormal filling = 1 at rest and 10 during IME) or NOR (LVH = 3, abnormal filling = 1 at rest and 9 during IME) (p < 0.02). LVMI was not related to LVEF. Although blood pressure was not different between MAC and MIC groups, it was significantly higher than in the NOR group. This study suggests that a high degree of albuminuria in hypertensive diabetics is associated with greater value for LVMI and an increased incidence of LVH independent of blood pressure level or systolic LV function. LVH is associated with abnormal LV filling. The degree of albuminuria may predict LVMI and LVH, which are associated with abnormal LV filling. This association of abnormal LV filling with albuminuria in hypertensive diabetic patients may account for their high risk of cardiovascular events.

Atrial septal aneurysm and patent foramen ovale are less prevalent in the Indo-Asian than in the Caucasian or Afro-Caribbean population.

UNLABELLED: Atrial septal aneurysm (ASA) and patent foramen ovale (PFO) are not uncommon during routine echocardiographic scanning and were reported to be associated with stroke, transient ischemic attacks, and migrainous headache. To assess the prevalence of ASA and PFO according to ethnicity, we retrospectively studied 887 consecutive referrals to a General Cardiology and Hypertension clinics. All participants underwent trans-thoracic echocardiography (TTE). In some patients, the TTE was repeated using bubble contrast. RESULTS: Atrial septal aneurysm was detected in 70 participants (7.9%) and PFO in 18 (2%). Atrial septal aneurysm, PFO, or their combination was detected in 12% of the Caucasian patients, 15% of the Afro-Caribbean, and 3.7% of the Indo-Asian patients. CONCLUSIONS: There was a lower prevalence of ASA and PFO and their combination in Indo-Asians and a higher rate in Afro-Caribbeans than in Caucasians. The higher prevalence in the Afro-Caribbean participants may contribute to the high incidence of stroke in black participants.