中国35～64岁人群胆固醇水平与10年心血管病发病危险的前瞻性研究

目的探讨我国35～64岁人群血清总胆固醇（TC）水平与心血管病（包括急性冠心病事件和急性脑卒中事件）发病危险的关系。方法采用前瞻性队列研究的方法,对1992年建立的11省市35—64岁队列人群共30384人的基线TC水平和1992-2002年发生的急性冠心病事件和急性脑卒中事件的关系进行分析。应用Cox比例风险模型对TC水平与心血管病发病危险进行多因素分析。结果（1）以TC〈3．64mmol／L（140mg／d1）组为对照,随着TC水平的增加,缺血性心血管病发病危险呈持续增加变化。（2）TC水平与不同类型的心血管病的关系有所差别：缺血性脑卒中事件发病危险从TC很低水平（〈3．64mmol／L）开始,随着TC水平的增加呈持续上升的变化;而出血性脑卒中事件与TC水平的关系缺乏一致性。多因素分析结果显示：与TC〈5．72mmol／L（220mg／d1）相比,TC≥5．72mmol／L时急性冠心病发病危险增加74％（RR=1．743,P〈0．01）,缺血性脑卒中发病危险增加12％（RR=1．119,P〉0．05）。（3）在缺血性心血管病事件中,5．9％可归因于高TC血症;其中11．7％的急性冠心病事件和2．9％的急性缺血性脑卒中事件可归因于高TC血症。（4）不同TC水平时,随着合并其他心血管病危险因素个数的增加,10年心血管病发病的绝对危险增加。结论从TC低水平〈3．64mmol／L（140mg／dl）开始,随着TC水平的增加缺血性心血管病的发病危险持续上升。应该加强多重危险因素的综合干预,以减少心血管病的综合危险。     

中国35～64岁人群白细胞计数与心血管病发病危险的前瞻性研究

目的 探讨我国35～64岁人群白细胞计数水平与不同类型心血管病(包括急性冠心病事件和急性脑卒中事件)发病危险的关系. 方法 采用前瞻性队列研究的方法,对1992年建立的11省市35～64岁队列人群共21 318人的基线白细胞计数水平和1992-2003年发生的急性冠心病事件和急性脑卒中事件的关系进行分析.应用Cox比例风险模型对白细胞计数水平与心血管病发病危险进行多因素分析. 结果 (1)白细胞计数从参照组4.0～4.9×109/L开始,随着白细胞计数水平的升高,缺血性心血管病事件及总心血管病事件累计人年发病率呈持续上升的变化,缺血性心血管病事件及总心血管病事件发病危险随白细胞计数的升高而增加.(2)白细胞计数水平与不同类型的心血管病发病危险的关系有所差别:与参照组(4.0～4.9×109/L)相比,随着白细胞计数的升高,急性冠心病事件发病危险及缺血性脑卒中事件发病危险上升;而出血性脑卒中事件与白细胞计数水平未见明显相关趋势.(3)多因素分析显示,当白细胞计数＞9.0×109/L时,总缺血性心血管病事件发病危险增加(95% CI:1.188～2.416),其RR是对照组的1.7倍. 结论 随着白细胞计数的升高,缺血性心血管病事件及总心血管病事件发病危险呈上升变化.     

中国35～64岁人群血清甘油三酯与心血管病发病危险的关系

目的 探讨我国35～64岁人群血清甘油三酯(TG)与心血管病发病危险的关系.方法 采用前瞻性队列研究的方法,利用中国多省市心血管病危险因素队列研究30 378人的资料,通过对基线血清TG不同水平人群12年间(1992-2004年)急性冠心病事件、缺血性脑卒中事件和出血性脑卒中事件发病风险进行比较,研究TG对各类心血管病发病风险的影响.结果 (1)TG与急性冠心病事件的发病危险有明确的关系.急性冠心病事件的人年发病率在TG水平较低时(TG≥1.15mmol/L)开始增加,TG水平上四分之一分位组(TG≥1.60 retool/L)人群的急性冠心病事件人年发病率是TG水平下四分之一分位组(TG＜0.81 retool/L)的2.7倍(168.4/10万,62.6/10万).(2)应用COX回归分析调整了多种其他危险因素后,TG水平对12年间急性冠心病的发病风险有独立的预测作用.分析未发现TG与缺血性脑卒中和出血性脑卒中的发病危险存在关联.结论 在35～64岁中国人群中,TG是急性冠心病事件发病的独立危险因素.急性冠心病事件的发病危险从TG≥1.15mmot/L即开始升高.     

apoE基因型与心脑血管病的前瞻性研究

目的探讨中国人群apoE基因型与不同类型心血管病（包括急性冠心病事件和急性脑卒中事件）发病危险的关系。方法采用前瞻性队列研究的方法,以北京市自然人群为研究对象,应用聚合酶链反应-限制性片段长度多态性技术（PCR-RFLP）进行APOE基因分型,对APOE基因型和随访10年发生的急性冠心病事件和急性脑卒中事件的关系进行分析。应用Cox比例风险模型对APOE基因型与心血管病发病危险进行多因素分析。结果（1）与apoE3基因型相比,E2及E3基因携带者缺血性心血管病（ICVD）事件发病危险明显增加;（2）APOE基因多态性与不同类型的心血管病发病危险的关系有所差别：与携带E3等位基因人群相比,携带E2和E4基因型的人群中急性冠心病事件发病危险及缺血性脑卒中事件发病危险明显上升;而出血性脑卒中事件与APOE基因多态性未见明显相关。携带E4等位基因的人群总缺血性心血管病事件发病危险有较大幅度增加,其RR是对照组的1.78倍;（3）在缺血性心血管病事件中,6.4%可归因于携带E2和E4基因型;其中6.2%的急性冠心病事件和7.3%的急性缺血性脑卒中事件可归因于E2和E4基因型。结论APOE基因多态性与ICVD的发病危险密切相关。在心血管病的综合危险评估中,对于基因的多态性应予以足够重视。     

中国35～64岁人群心血管病危险因素与发病危险预测模型的前瞻性研究

目的　探讨中国人群主要心血管病危险因素与心血管病发病绝对危险的关系 ,建立中国人群心血管病发病危险的预测模型。方法　采用前瞻性队列研究的方法 ,对 1992年建立的 11省市 35～ 6 4岁队列人群 [中国多省市队列研究 (ChinaMulti provincialCohortStudy ,CMCS) ]共 3172 8人基线危险因素水平和 1992～ 2 0 0 2年发生的心血管病事件 (包括急性冠心病事件和急性脑卒中事件 )进行单因素和多因素分析。结果　 (1) 10年累积平均急性冠心病事件发病率男性是 1 4 1% ,女性是 0 6 0 %。缺血性脑卒中事件的发病率男性是 2 0 2 % ,女性是 1 37%。 (2 )利用预测模型计算不同危险因素水平与缺血性心血管病发病概率 ,结果显示 :随着危险因素个数的增加心血管病发病的绝对危险增加 ,不同危险因素之间有协同作用 ,不同的危险因素组合对心血管病发病危险的作用强度有所差别。 (3)我国 35～ 6 4岁人群缺血性心血管病发病危险概率 <10 %者占 95 4 % ,发病危险概率≥ 10 %者占 4 6 % ,发病危险概率≥ 2 0 %者只占 0 8%。而缺血性心血管病事件的 2 5 5 %发生在发病危险概率≥ 10 %的人群中。结论　危险因素与心血管病发病绝对危险的评估比相对危险度具有更重要的公共卫生意义。在评价不同个体的心血管病危险时不应     

高密度脂蛋白胆固醇与心脑血管病相关性前瞻研究

目的 探讨我国35～64岁人群血清HDL-C水平与急性冠心病事件和急性卒中事件发病危险的关系.方法 采用前瞻性队列研究的方法 ,对11省市35～64岁队列人群共30 384人基线HDL-C水平和1992-2003年发生的急性冠心病和急性卒中事件关系进行分析.应用Cox比例风险模型对HDL-C水平与心血管病发病危险进行多因素分析.结果 (1)与对照组相比,随着HDL-C水平的降低,缺血性心血管病(ICVD)事件发病危险呈持续增加.(2)HDL-C水平与不同类型的心血管病发病危险的关系有所差别,随着HDL-C水平的降低,急性冠心病事件发病危险及缺血性卒中事件发病危险明显上升;而出血性卒中事件与HDL-C水平的关系差异无统计学意义.低HDL-C血症组急性冠心病发病的危险增加45%(RR=1.45,P＜0.05),缺血性卒中发病的危险增加53%(RR=1.53,P＜0.01).(3)在缺血性心血管病事件中,6.4%可归因于HDL-C水平降低;其中6.2%的急性冠心病事件和7.3%的急性缺血性卒中事件可归因于低HDL-C血症.结论 从HDL-C≥1.56mmol/L开始,随着HDL-C水平的降低,ICVD的发病危险明显上升.在血脂异常的防治中,对于低HDL-C应予以足够重视.     

中国11省市队列人群基线血压和7年累积心血管病发病危险的前瞻性研究

目的：以较大人群、较广的地理覆盖面的前瞻性队列研究结果提供中国人血压水平与心血管病发病危险最化关系的数据;探讨收缩压和舒张压作为危险因素标识或致病因素在与心血管病的发病危险的关系上存在的差别;分析血压对急性脑卒中和冠心病事件发病的影响是否存在差别及控制血压对预防这两种疾病的公共卫生意义;初步评价现行的高血压诊断、治疗和分级标准。方法：对1992年建立的11省市35－64岁队列人群共29488人基线血压水平和1992－1999年共138177．1观察人年中生心血管病（包括脑卒中和冠心病）事件发病的数据进行单因素和多因素分析。结果：对收缩压和舒张压分别进行的单因素和多因素分析显示,两均可作为预测生心血管病事件发病危险的有效标识,但收缩压水平对急性心血管病事件,特别是脑卒中危险的影响强度明显大于舒张压,收缩压≥180mmHg（1mmHg=0.133kPa)组与收缩压＜120mmHg组人群相比,生心血管事件发病危险单因素分析时高22倍（脑座中31倍,冠心病8倍）,多因素分析时高11倍（脑卒中16倍,冠心病4倍）。血压对于与急性脑卒中事件和急性冠心病事件的影响无论在强度、影响方式和预防的公共卫生意义上存在明显差别,人群中79．7％的脑卒中事件可归因于血压的升高,但只有36．6％的冠心病事件可归因于血压的增高因血压各分级中,心血管事件的发病危险随其他危险因素存在的数量而上升。结论：高血压是目前中国人群最重要的心血管病危险因素,有效的防治高血压是减少我国心血管病负担最重要和最关键的环节。     

缺血性心血管病:一个反映血脂异常潜在危险的新指标

目的　提出一个能够反映我国人群心血管病发病特点的、用于评价血脂异常潜在威胁的新指标。方法　资料包括中国心血管病流行病学多中心协作研究 1991～ 2 0 0 0年心血管病发病监测资料和该项目在“六五”和“八五”期间建立的 2个队列随访资料以及中美心肺疾病流行病学合作研究队列随访资料。分析冠心病事件和缺血性脑卒中事件绝对危险和相对危险随基线血清胆固醇水平升高的变化 ,用Cox比例风险模型调整可能的混杂因素。提出将冠心病事件和缺血性脑卒中事件合计 ,统称为缺血性心血管病事件。结果　 (1)监测资料和队列随访资料均证实我国人群缺血性脑卒中的发病率约为冠心病事件的 2倍 ,二者的联合终点事件约占所有心血管病事件发病的 6 5 %。 (2 )在3个现有的大样本长期观察的队列人群中 ,血清总胆固醇与冠心病事件和缺血性脑卒中事件年龄标化发病均呈显著正相关。 (3)除“八五”队列男性外 ,所有队列在相同血清总胆固醇水平均显示缺血性脑卒中事件年龄标化发病率高于冠心病事件发病率。如 ,当TC≥ 6 2 4mmol L (1mmol L =38 6 7mg dl)时 ,冠心病事件发病的年龄标化发病率仅约为 (110～ 130 ) 10万 ,而缺血性心血管病事件的年龄标化发病率为 (36 0～ 5 5 0 ) 10万。结论　缺血性心血管病事件占我国心     

中国35～64岁人群血压水平与10年心血管病发病危险的前瞻性研究

目的探讨我国35～64岁人群血压水平与心血管病发病危险的关系,为《中国高血压防治指南》的修订工作提供流行病学数据。方法采用前瞻性队列研究的方法,对1992年建立的11省市35～64岁队列人群共31728人的基线血压水平和1992～2002年发生的心血管病(包括冠心病和脑卒中)事件的关系进行分析。结果(1)以血压110～119／75～79mmHg(1mmHg=0．133kPa)为对照,血压在120～129／80～84mmHg时,心血管病发病危险增加了1倍(RR=2．09);血压在140～149／90～94mmHg时,心血管病发病危险增加了2倍以上(RR=3．23);当血压≥180／110mmHg时,心血管病发病危险增加了10倍以上(RR=11．81)。(2)与理想血压相比,2级高血压时,急性冠心病事件发病的危险是理想血压组的2．3倍,急性缺血性脑卒中和急性出血性脑卒中发病的危险分别是理想血压组的4．9倍和11．7倍。(3)在总的心血管病事件中,36．1％可归因于高血压;其中44．0％的急性脑卒中事件和23．7％的急性冠心病事件可归因于高血压。(4)不同血压水平时,随着合并其他心血管病危险因素个数的增加,10年心血管病发病的综合危险增加。结论血压水平从110／75mm Hg开始,随着血压水平的增加,心血管病发病危险持续上升,所以将某个血压水平作为高血压的诊断标准是人为制订的。应该加强多重危险因素的综合干预,以减少总的心血管病的发病危险。     

空腹血糖受损新标准对其患病率和缺血性心血管病发病危险的影响

目的评价2003年美国糖尿病协会新的空腹血糖受损标准对中国35～64岁人群空腹血糖受损率的影响以及与缺血性心血管病发病危险的关系。方法以中国多省市前瞻性队列研究的数据为基础,对30378人基线血糖水平的分布特点以及10年随访期间发生的缺血性心血管病（包括冠心病和缺血性脑卒中）事件关系进行分析。结果（1）依据新的空腹血糖受损的标准,我国35～64岁人群空腹血糖受损率从6．9％上升到21．6％,增加了2.1倍;（2）按基线血糖水平分为4个亚组,随着血糖水平的升高,其他传统心血管病危险因素的比例增加;（3）缺血性心血管病人年发病率和血糖单因素分析显示,随着血糖水平的增加男女两性缺血性心血管病发病危险增加,并达到统计学意义;（4）多因素分析显示,在调整了其他传统的心血管病危险因素后,空腹血糖受损新的标准（由6．11mmol／L降为〈5．55mmol／L）对男性缺血性心血管病有独立的影响作用（RR=1．302,95％CI=1．021～1．660）;对女性缺血性心血管病发病危险缺乏独立的影响作用（RR=1．255,95％CI=0．887～1．776）。结论依据新标准中国35～64岁人群空腹血糖受损率增加了2倍以上。随着血糖水平的增加伴有其他传统的危险因素的比例及缺血性心血管病的人年发病率增加,多因素分析后空腹血糖受损新切点增加男性缺血性心血管病发病的危险。     

Smoking raises the risk of total and ischemic strokes in hypertensive men.

To examine the relation between cigarette smoking and risk of stroke and coronary heart disease among Japanese, we conducted a 14-year prospective study of 3,626 men aged 40-69, initially free from history of stroke and coronary heart disease. We identified 257 strokes (75 hemorrhagic and 173 ischemic strokes) and 100 coronary heart disease events. When we adjusted for age and other cardiovascular risk factors, a significant excess risk among current smokers of > 20 cigarettes/day vs. never-smokers was found for total stroke (relative risk (RR) = 1.6 (95% confidence interval (CI), 1.1-2.4)). The excess risk of total stroke was particularly evident among hypertensives (RR = 2.3 (1.2-4.4)). The multivariate RR of ischemic stroke was 1.6 (1.0-2.5) for total subjects, and 2.2 (1.0-5.0) among hypertensives. Significant excess risks among current smokers of > 20 cigarettes/day vs. never-smokers were also found for coronary heart disease (RR = 4.6 (1.6-12.9)) and total cardiovascular disease (1.9 (1.3-2.7)). The estimated proportion of the events attributable to current smoking was 30 (95% CI, 11-44)% for total stroke and 34 (5-54)% for coronary heart disease. In conclusion, current smoking of > 20 cigarettes per day increased the risk of both total stroke and ischemic stroke among Japanese middle-aged men, and particularly among middle-aged hypertensive men.     

Retrospective analysis of cardiovascular outcomes in patients with type 2 diabetes mellitus after the first acute myocardial infarction

We retrospectively analyzed survival in patients with type 2 diabetes mellitus (DM) after first acute myocardial infarction (AMI). The study was conducted in 5 sites in Poland and involved 521 patients who survived more than 30 days after AMI. In the 5-year period after the acute event, we investigated the following cardiovascular (CV) outcomes: death (overall mortality), next MI, stroke, hospitalization due to acute coronary symptoms (HACS), and composite outcomes (whichever occurred first). We also assessed: age, smoking habit, obesity, hypertension, dyslipidemia and coronary artery disease (CAD) diagnosed before AMI, and gender. 269 patients (52%) suffered one of the outcomes from the composite CV endpoint. HACS was the first event in 164 cases, MI in 59, death in 32, and stroke in 14 patients. Analyzing the prevalence of individual CV events, we found: HACS in 184 patients (35%), next MI in 79 patients (15%), death in 59 patients (11%), and stroke in 30 patients (6%). Only dyslipidemia, arterial hypertension, and CAD were independent risk factors with an impact on composite CV endpoint. Other analyzed risk factors like smoking and obesity did not have independent effects on the CV risk. In the retrospective analysis, we found that HACS was the most frequent CV event in individuals with type 2 DM after AMI. The CV risk in type 2 diabetics who suffered at least one myocardial infarction was further increased in those with coexisting dyslipidemia, arterial hypertension or CAD. These findings support the current guidelines which recommend aggressive management of CV risk factors including hypertension, dyslipidemia and CAD before a first myocardial infarction.     

Epidemiological evidence of type 2 diabetes mellitus, metabolic syndrome, and cardiovascular disease in Japan

Although epidemiological studies in the US and Europe have confirmed that type 2 diabetes mellitus (DM) is associated with an increased risk of cardiovascular disease (CVD) events, evidence is limited in Japan. Earlier studies in Japan showed that hypertension has a major effect on atherosclerosis in relatively lean subjects, with type 2 DM contributing more to CVD events, because of a decline in blood pressure levels in both sexes and an increase in body mass index in men. Recent cohort studies in Japan using baseline assessments carried out during the 1990s have confirmed that type 2 DM is associated with an increased risk of coronary heart disease (CHD) and all types of stroke, except hemorrhagic stroke. In addition, the metabolic syndrome, a constellation of metabolic risk factors, was shown to predict CVD events in Japanese people, independent of the presence or absence of obesity. The strong association of type 2 DM with CHD (hazard ratio: 1.5-4) and ischemic stroke (hazard ratio: 2-4) events was confirmed in Japanese adults. Individuals with impaired glucose tolerance or impaired fasting glucose were also shown to have an increased risk of a CHD event, but not a stroke.     

The association between lipid levels and the risks of incident myocardial infarction, stroke, and total mortality: The Cardiovascular Health Study

OBJECTIVES: To assess the association between lipid levels and cardiovascular events in older adults. DESIGN: A prospective population-based study. SETTING: Four field centers in U.S. communities. PARTICIPANTS: A total of 5,201 adults aged 65 and older living in U.S. communities, plus a recruitment of 687 African Americans 3 years later. MEASUREMENTS: Fasting lipid measures included low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol, and triglycerides. RESULTS: At baseline, 1,954 men and 2,931 women were at risk for an incident myocardial infarction (MI) or stroke. During an average 7.5-year follow-up, 436 subjects had a coronary event, 332 had an ischemic stroke, 104 a hemorrhagic stroke, and 1,096 died. After adjustment, lipid measures were not major predictors of the outcomes of MI, ischemic stroke, hemorrhagic stroke, and total mortality. For total cholesterol and LDL-C, the associations with MI and ischemic stroke were only marginally significant. HDL-C was inversely associated with MI risk (hazard ratio=0.85 per standard deviation of 15.7 mg/dL, 95% confidence interval=0.76-0.96). For the outcome of ischemic stroke, high levels of HDL-C were associated with a decreased risk in men but not women. Lipid measures were generally only weakly associated with the risks of hemorrhagic stroke or total mortality. CONCLUSION: In this population-based study of older adults, most lipid measures were weakly associated with cardiovascular events. The association between low HDL-C and increased MI risk was nonetheless strong and consistent.     

Identification of genetic factors and development of genetic risk diagnosis systems for cardiovascular diseases and stroke.

BACKGROUND: Polymorphisms of GJA4 and CYBA and of PAI1 and MMP3 are associated with myocardial infarction (MI) in men and women, respectively. In addition, several polymorphisms associated with restenosis after percutaneous coronary intervention, coronary artery spasm, or hypertension have been identified. More recently, a large genetic epidemiological study was performed to identify additional gene polymorphisms that confer susceptibility to cardiovascular diseases, stroke, and other complex diseases. METHODS AND RESULTS: The relationship of 202 polymorphisms in 152 candidate genes to MI, hypertension, ischemic or hemorrhagic stroke, metabolic syndrome, type 2 diabetes mellitus, obesity, or in-stent restenosis were examined in 5,000 unrelated Japanese individuals. Of these, 14 polymorphisms related to MI, 8 to atherothrombotic cerebral infarction, 9 to intracerebral hemorrhage, and 10 to subarachnoid hemorrhage were identified. This information was then used to develop risk diagnosis systems to predict the future risk for development of each disease in a given individual. CONCLUSIONS: Identification of gene polymorphisms that confer susceptibility to cardiovascular diseases or stroke and the development of genetic risk diagnosis systems may contribute to the personalized prevention of these conditions.     

Impact of pre‐existing hypertension and control status before atrial fibrillation onset on cardiovascular prognosis in patients with non‐valvular atrial fibrillation: A real‐world database analysis in Japan

Hypertension is an important risk factor for non‐valvular atrial fibrillation (NVAF) and its prognosis. However, there is no study to clarify the impact of pre‐existing hypertension and BP control status before the onset of AF on the prognosis after the onset of AF. This retrospective real‐world cohort analysis used data from the Japan Medical Data Center Co., Ltd database. The presence of NVAF and hypertension, plus the occurrence of adverse events, was based on ICD‐10 codes in the database. The primary composite AF‐related cardiovascular event end point included ischemic stroke, hemorrhagic stroke, and acute myocardial infarction. Of the 21 523 patients identified as having new‐onset NVAF between January 2005 and June 2016, 7885 had blood pressure (BP) data before the onset of NVAF available and were included in the analysis (4001 with pre‐existing hypertension and 3884 without pre‐existing hypertension). The rate of primary composite end point events was 10.3 and 4.4 per 1000 patient‐years in patients with and without hypertension, respectively (P < .001). In addition, lower systolic BP (<120 mm Hg) before the onset of NVAF was associated with a lower incidence of cardiovascular events after the development of NVAF (P < .001). This highlights the importance of earlier and tighter 24‐hour BP control before the onset of NVAF in patients with hypertension, not only for reducing the occurrence of new‐onset of NVAF, but also for reducing both hemorrhagic and ischemic cardiovascular events after the onset of NVAF.     

Application of U.S. guidelines in other countries: aspirin for the primary prevention of cardiovascular events in Japan

PURPOSE: Clinical guidelines developed in the United States are used frequently in other countries without assessment of their appropriateness in non-U.S. populations. We explored the relevance of recent U.S. guidelines for the use of aspirin for the primary prevention of cardiovascular events in the Japanese population. METHODS: From a systematic search of published data, estimates were derived for rates of coronary heart disease, hemorrhagic stroke, and major gastrointestinal bleeding for the Japanese population and for subgroups with different risk factors. Odds ratios derived from meta-analyses were used to assess the potential benefits and risks of aspirin use. RESULTS: The estimated incidence of coronary heart disease in middle-aged men in Japan is lower than in the United States (1.57 vs. 6.0 per 1000 person-years), while that of hemorrhagic stroke is higher (1.14 vs. 0.37 per 1000 person-years). Because of higher baseline rates of hemorrhagic diseases, the expected reduction in cardiovascular events with aspirin use would be offset by a greater increase in hemorrhagic complications for women and most men in Japan, except for those with both hypertension and diabetes. To achieve the same 2:1 ratio of coronary heart disease events avoided to hemorrhagic events caused that is implied by the 3% threshold for 5-year coronary disease risk in U.S. guidelines, a 6% to 14% risk threshold, depending on patient age, seems appropriate for recommending aspirin in Japanese patients. CONCLUSION: The thresholds of antiplatelet therapy for Asian populations should be two to five times higher than those for the U.S. population because of higher risks of hemorrhagic complications. The assumptions and implications of U.S. guidelines should be evaluated before use in other countries.     

阿司匹林在心血管病一级预防的地位

阿司匹林作为急性心肌梗死和冠心病二级预防的基础药物已得到广泛认可,然而近年来关于阿司匹林对心血管疾病的一级预防依然存在争议。阿司匹林可降低心脑血管事件的发生率,但同时又可增加出血事件。如何将其合理地运用在心血管疾病一级预防中使更多的患者获益是临床工作者的一大难题。越来越多的大规模临床研究表明阿司匹林作为心血管疾病一级预防药物的关键在于把握危险分层,进一步评价患者的状况,规范使用阿司匹林将会有效地减少心血管疾病的风险。与此同时国外许多指南及我国专家的共识均能指导医生在心血管疾病一级预防中规范地运用阿司匹林。     

Hyperinsulinemia and the risk of cardiovascular death and acute coronary and cerebrovascular events in men: the Kuopio Ischaemic Heart Disease Risk Factor Study

BACKGROUND: The role of hyperinsulinemia as a cardiovascular risk factor is controversial. We studied whether hyperinsulinemia is independently associated with increased cardiovascular morbidity and mortality. METHODS: Fasting serum insulin level and other cardiovascular risk factors were determined in 1521 men in eastern Finland aged 42 to 60 years with neither cardiovascular disease nor diabetes at baseline. Forty-five cardiovascular deaths, 110 acute coronary events, 48 strokes, and 163 any cardiovascular events occurred during an average follow-up of 9.5 years. A total of 163 cardiovascular events (45 cardiovascular deaths, 110 acute coronary events, and 48 strokes) occurred during an average follow-up of 9.5 years. RESULTS: In Cox regression analysis adjusting for age and examination years, fasting serum insulin level as a continuous variable was directly associated with the risk of cardiovascular death (P = .006), acute coronary events (P = .04), and stroke (P = .02). Men with insulin levels of 52 to 66 pmol/L, 67 to 89 pmol/L, and 90 pmol/L or more (3 highest quartiles) had 1.4-fold (95% confidence interval, 0.5-3.7), 1.4-fold (95% confidence interval, 0.5-3.7), and 2.5-fold (95% confidence interval, 1.0-5.9; P = .05) cardiovascular mortality, respectively, compared with men with insulin levels of less than 52 pmol/L (lowest quartile) (P = .04 for linear trend). Adjustment for serum lipid levels, blood pressure, and obesity reduced the excess cardiovascular mortality in the highest insulin quartile by 7%, 33%, and 67%, respectively. There were no statistically significant differences in the incidence of acute coronary events and stroke between the insulin quartiles. CONCLUSIONS: Hyperinsulinemia had a modest association with increased cardiovascular mortality in middle-aged men. This relationship was largely explained by obesity, hypertension, and dyslipidemia. Hyperinsulinemia had even weaker associations with the risk of acute coronary event and stroke.