Women in Pakistan have a greater burden of clinical cardiovascular risk factors than men

AIMS: Migrant South Asian population in the West, particularly women, is more predisposed to central obesity and metabolic syndromes than native Caucasians. However, the burden of coexistence of clinical risk factors for cardiovascular disease (CVD) and associated gender disparities in native population of South Asia are not known. We analyzed the National Health Survey of Pakistan (NHSP) (1990-1994) data to study the same in the population of Pakistan. METHODS: Data from 9442 individuals age 15 years or over from the National Health Survey of Pakistan (NHSP) (1990-1994) was analyzed. The primary outcome was defined as the coexistence of at least two of the following five clinical risk factors for CVD. Hypertension (systolic blood pressure > or = 140 mm Hg, or diastolic blood pressure > or = 90 mm Hg, or current therapy with antihypertensive medications); diabetes (non-fasting blood glucose > or = 140 mg/dl (7.8 mmol/l), or known history of diabetes); proteinuria (dipstick urine protein > 1+); hyperlipidemia (random blood cholesterol > or = 200 mg/dl (5.17 mmol/l)), and central obesity (waist circumference of > or = 80 cm in women and > or = 90 cm in men. RESULTS: The overall prevalence (95% confidence intervals) of the coexistence of risk factors for CVD was 17.2% (16.4-18.0%): 13.0% (12.1-14.1%) in men and 20.9% (19.8-22.0%) in women (p < 0.001). Multivariate analysis revealed that men had at significantly lower odds of coexistence of risk factors than women with OR, 95% CI of 0.53, 0.47-0.61, and this difference increased in magnitude with age (interaction p < 0.001). In addition to Muhajir, Sindhi and Pashtun vs Punjabi ethnicity, factors independently associated with primary outcome were age (OR, 95% CI) (1.06, 1.05-1.06, for each one year increase), urban dwelling vs rural dwelling (1.45, 1.24-1.70), high (1.97, 1.61-2.45) and mid (1.44, 1.23-1.70) vs low socioeconomic status, body mass index (1.17, 1.15-1.18, for each one kg/m(2) increase), and high consumption of meat (1.77, 1.52-2.06) and ghee (1.26, 1.00-1.54). CONCLUSIONS: Potentially modifiable factors including obesity and saturated fat intake are associated with increased prevalence of CVD risk factors. The high burden of multiple CVD risk factors in women compared to men highlight the need for targeting this vulnerable segment of population in CVD prevention programs in Pakistan, and, possibly neighbouring countries.     

Sex differences in risk factor control of treated hypertensives: a national primary healthcare-based study in Sweden.

BACKGROUND: To evaluate potential sex differences, this study aimed to investigate blood pressure and lipid control and other risk factors for cardiovascular disease in treated hypertensive (tHT) patients from primary healthcare. DESIGN AND METHODS: This cross-sectional survey of tHT patients was carried out between 2002 and 2005 by 264 primary care physicians from Sweden who consecutively recruited 6537 tHT patients (48% men and 52% women) from medical records. RESULTS: tHT men more often reached the treatment goal for systolic/diastolic blood pressure, less than 140/90 mmHg, than tHT women (30 vs. 26%, P<0.01). Men had lower systolic blood pressure than women, however, women had lower diastolic blood pressure and higher pulse pressure. More tHT women had total cholesterol>or=5.0 mmol/l than corresponding men (75 vs. 64% P<0.001). Men more often had diabetes (25 vs. 20% P<0.001), left ventricular hypertrophy (20 vs. 16% P<0.001), and microalbuminuria (24 vs. 16% P<0.001). Women were more often treated with diuretics (64 vs. 48%) and beta-receptor blockers (54 vs. 51%), and men more often treated with angiotensin-converting enzyme inhibitors (27 vs. 18%), calcium channel blockers (34 vs. 26%), and lipid-lowering drugs (34 vs. 29%). CONCLUSION: A need still exists for more intensified treatment of elevated blood pressure and hypercholesterolemia, especially in women. In hypertensives of both sexes, smoking and other risk factors also need to be addressed to reduce the risk of cardiovascular disease.     

The majority of nondipping men do not have increased cardiovascular risk: a population-based study

OBJECTIVE : To investigate whether nondipping and diabetes are independently related to metabolic risk profile and prevalence of target organ damage in a population setting. METHODS : A population-based cohort of 70-year-old men (n = 1057) was examined with 24-h ambulatory blood pressure monitoring, euglycemic hyperinsulinemic clamp and lipid and glucose determinations. We defined nondipping as a night-day systolic blood pressure ratio >or= 1 (n = 66). Urinary albumin excretion rate and echocardiographically determined left ventricular geometry were used as indices of target organ damage. RESULTS : Nondipping was not related to hypertension, but diabetes was more common in nondippers (26%) than in dippers (14%, P < 0.05). Nondiabetic nondippers did not differ from dippers regarding insulin sensitivity, plasma glucose or lipids. However, nondipping in diabetic subjects was associated with the most pronounced impairments in body mass index, serum triglycerides and fasting plasma glucose. Measures of target organ damage did not differ between nondippers and dippers in the whole population, but an interaction (P < 0.05) between nondipping and diabetes contributed to an increased left ventricular mass in diabetic nondippers. The urinary albumin excretion rate was independently related to diabetes. CONCLUSIONS : In this population study, an interaction between diabetes and nondipping was demonstrated regarding fasting plasma glucose, lipid levels and left ventricular mass, indicating that nondipping is a marker of risk in diabetic subjects. However, in the nondiabetic majority of the population, nondipping was not associated with either metabolic disturbances or target organ damage.     

Advanced lipoprotein profile identifies atherosclerosis better than conventional lipids in type 1 diabetes at high cardiovascular risk

Background and aimsPeople with type 1 diabetes (T1D) present lipoprotein disturbances that could contribute to their increased cardiovascular disease (CVD) risk. We evaluated the relationship between lipoprotein alterations and atherosclerosis in patients with T1D.Methods and resultsCross-sectional study in subjects with T1D, without previous CVD, but high-risk (≥40 years, nephropathy, or ≥10 years of evolution of diabetes with another risk factor). The presence of plaque (intima-media thickness ≥1.5 mm) in the different carotid segments was determined by ultrasound. The advanced lipoprotein profile was analysed by magnetic resonance imaging (¹H NMR). We included 189 patients (42% women, 47.8 ± 10.7 years, duration of diabetes 27.3 ± 10.1 years, HbA1c 7.5% [[7], [8]]). Those with carotid plaques (35%) were older, with longer diabetes duration, had a higher prevalence of hypertension, and showed lower and smaller LDL particles (LDL-P) and HDL particles (HDL-P), but higher VLDL particles (VLDL-P). Some LDL, HDL and VLDL-related parameters were associated with atherosclerosis in sex, age and statin use adjusted models (p < 0.05), but after adjusting for multiple confounders, including conventional lipid parameters, only HDL-P (OR 0.440 [0.204–0.951]; p = 0.037), medium HDL-P (OR 0.754 [0.590–0.963]; p = 0.024), HDL-P cholesterol content (OR 0.692 [0.495–0.968]; p = 0.032), ¹H NMR LDL-P number/conventional LDL-cholesterol (OR 1.144 [1.026–1.275]; p = 0.015), and ¹H NMR non-HDL particle number/conventional non-HDL-cholesterol ratios (OR 1.178 [1.019–1.361], p = 0.026) remained associated with atherosclerosis.ConclusionsIn adults with T1D at high-risk, variables related to HDL, LDL and total atherogenic particle number are independently associated with preclinical atherosclerosis. Advanced lipoprotein profiling could be used to identify those at the highest risk of CVD.     

Tobacco dependence: first risk factor of atherosclerosis. Survey among smokers and non-smokers in group dynamics

Several epidemiological and experimental studies have demonstrated an increased risk of atherosclerosis in smokers. The secondary prevention of this risk factor is only possible, presently, through anti-tobacco consultations. Several approaches are possible but there are many recurrences within the year following the wean-off. In a group dynamics, including patients having tried another method, we have conducted an investigation among inveterate smokers (n = 106), former smokers (n = 50) and a group of non-smokers (n = 34). Group dynamics remains a suitable method for smokers willing to get rid of their addiction. The number of daily cigarettes consumed by inveterate smokers is considerably and lastingly reduced, and 27 p. cent of the patients quit smoking. Monitoring of laboratory tests (HbCo, Blood count, HDL-cholesterol, thiocyanate, etc.), electrocardiogram and chest X-Ray, completes this weekly consultation and permits a stronger motivation for the smoker to quit smoking. Sometimes associated with acupuncture or homeopathy, this method permits a progressive de-conditioning from tobacco addiction.     

Older women with age-related macular degeneration have a greater risk of falls: a physiological profile assessment study

OBJECTIVES: To determine whether older women with exudative age-related macular degeneration (AMD) are at greater risk of falls.
DESIGN: Cross-sectional study.
SETTING: A hospital-based ophthalmology clinic in Vancouver, Canada.
PARTICIPANTS: One hundred fifteen older (aged ≥70) community-dwelling women with exudative AMD (AMD cohort) and two control groups: 54 community-dwelling women without exudative AMD drawn from the same community (non-AMD cohort) and 341 community-dwelling Australian women (Australian normative cohort).
MEASUREMENTS: Participants were assessed for falls risk using the short-form Physiological Profile Assessment (PPA), which provides a fall risk index score and subcomponent measures of vision, proprioception, strength, reaction time, and postural sway.
RESULTS: The mean fall risk index score in the AMD cohort (3.20) was significantly greater than that of the non-AMD cohort (1.21; P <.001), and fall risk scores increased with age to a greater extent in the AMD cohort. The higher fall risk scores in the AMD cohort resulted from significantly worse performance on each PPA test, not just the test of vision. The AMD cohort also performed worse than the Australian normative cohort in tests of vision, reaction time, and postural sway.
CONCLUSION: Older women with AMD have impaired balance, slow visual reaction times, and poor vision, which in combination result in a significantly greater risk of falls than population norms. These deficits are clearly indicated in the physiological falls profile for the group. Strategies to enhance balance may be particularly beneficial to prevent falls in this group.     

Multiple risk factors of periodontal disease: a study of 9260 Japanese non-smokers

Background:   Periodontal disease (PD) is a lifestyle-related disease. Risk factors include cigarette smoking and diabetes mellitus (DM). Diabetes mellitus, obesity, hypertension and hyperlipidemia are the main determinants of the metabolic syndrome that may be derived from insulin resistance (IR). In the present study, we examine the relationships between PD and IR-related factors.
Methods:   This is a cross-sectional study of 9260 non-smoking urban Japanese. The subjects were comprised of three groups, aged 40, 50 and 60 years. Periodontal status was evaluated using the Community Periodontal Index of Treatment Needs (CPITN). Serum samples were analyzed with an automated spectrophotometer.
Results:   Logistic regression analysis of the data showed that age ( P  = 0.0001), sex (male, P  = 0.0045), body mass index (BMI, P  = 0.017), mean blood pressure (mBP, P  = 0.0297) and fasting plasma glucose (FPG, P  = 0.0001) were the variables significantly associated with the prevalence of PD. There was a negative correlation between serum low dense lipoprotein cholesterol (LDL) and PD ( P  = 0.0001). In the age-adjusted profiles, sex (male, P  < 0.01), mBP ( P  < 0.01) and FPG ( P  < 0.001) had a significantly correlation with PD at age 60, while an inverse correlation between LDL and the prevalence of PD was seen only in the 40-year-old group ( P  < 0.001).
Conclusion   This is the first study showing that mBP and LDL are factors that may determine the prevalence of PD. Lifestyle-related factors could play an important role in the progression of PD.     

Perceptions of e-cigarettes: a comparison of adult smokers and non-smokers in a Mechanical Turk sample

Background: Given plans to extend its regulatory authority to e-cigarettes, the Food and Drug Administration (FDA) urgently needs to understand how e-cigarettes are perceived by the public. Objectives: To examine how smoking status impacts adult perceptions and expectations of e-cigarettes. Methods: We used Mechanical Turk (MTurk), a “crowdsourcing” platform, to rapidly survey a large (n = 796; female = 381; male = 415), diverse sample of adult ever (44%) and never smokers (56%), including ever (28%) and never (72%) users of e-cigarettes. Results: Smokers and non-smokers learned about e-cigarettes primarily through the internet and conversations with others. Ever smokers were more likely than never smokers, and female current smokers were more likely than female former smokers, to have learned about e-cigarettes from point of sale advertising (p’s < 0.05) and to believe that e-cigarettes help smokers quit (ps < 0.05). Among never users of e-cigarettes, current smokers were more likely than never smokers and former smokers to report that they would try e-cigarettes in the future (ps < 0.01). Current smokers’ top reason for wanting to try e-cigarettes was to quit or reduce smoking (56%), while never and former smokers listed curiosity. In contrast, female current smokers’ top reason for not trying e-cigarettes was health and safety concerns (44%) while males were deterred by expense (44%). Conclusions: Adult smokers and non-smokers have different perceptions and expectations of e-cigarettes. Public health messages regarding e-cigarettes may need to be tailored separately for persons with and without a history of using conventional cigarettes. Tailoring messages by gender within smoker groups may also improve their impact.     

Hypertensive type I diabetics have a higher level of microalbuminuria than normotensives irrespective of blood glucose equilibrium

Micro-albuminuria, glycosylated haemoglobin and creatinine clearance were measured in 28 insulin dependent and 8 insulin requiring diabetic patients (17 males aged 45 +/- 14.4 and 19 females aged 40 +/- 17 years). Twelve had retinopathy and six had high blood pressure. There was no statistical difference of duration of diabetes, creatinine clearance and glycosylated haemoglobin between patients with normal microalbuminuria and patients with hyper microalbuminuria. There was no correlation between glycosylated haemoglobin and micro-albuminuria, between creatinine clearance and micro-albuminuria, and between creatinine clearance and glycosylated haemoglobin. Patients with retinopathy did not have significantly higher levels of micro-albuminuria. Hypertensive patients had a significantly higher micro-albuminuria (p = 0.03, m = 45.10 +/- 56) compared with normotensive patients (m = 15.49 +/- 17.54). Glycosylated haemoglobin did not differ whether patients were normo or hypertensive. Hypertensive patients were significantly older (p = 0.01) than normotensive. The lack of difference in glycemic control between normo and hypertensive diabetics suggests that diabetes and hypertension are two independent cumulative risk factors of micro-albuminuria. Hypermicro-albuminuria may be secondary to microangiopathy in young diabetics and secondary to hypertension in old diabetics.     

Fasting insulin is a stronger cardiovascular risk factor in women than in men

Diabetes is a stronger risk factor for cardiovascular disease (CVD) in women than in men. It is not known whether there is also a sex difference in the association between hyperinsulinaemia, reflecting insulin resistance, and CVD. Fasting insulin was assessed with a specific assay in 6916 fasting, non-diabetic subjects of the PREVEND study without a prior history of CVD. Major Adverse Cardiovascular Events (MACE) (defined as CVD morbidity and CVD mortality) were prospectively recorded after the baseline survey. Cox-regression models were used to investigate the association of fasting insulin with subsequent development of MACE. Fasting insulin was 54 [38-77]pmol/l in women (age 48+/-12yrs) and 57 [40-88] pmol/l in men (age 49+/-13yrs). During follow-up for 7.5 [6.9-7.8]yrs, 98 cardiovascular events were recorded in 3626 women and 242 events in 3290 men. There was a significant (P<0.001) interaction between sex and fasting insulin for MACE, with the strongest association in women. In women, there was a logarithmic association for insulin with MACE, independent of age, alcohol consumption, and smoking (HR=1.50 [95% CI 1.17-1.91] per doubling of insulin, P=0.001). In men, for a similar multivariate model, there was a logarithmic association (HR=1.13 [95% CI [0.97-1.32] per doubling of insulin, P=0.1). Further adjustment for components of the insulin resistance syndrome weakened the association more in men than in women. With HOMA instead of insulin, results were essentially similar. In parallel with diabetes, fasting hyperinsulinaemia reflecting insulin resistance in non-diabetic subjects is associated with an increased risk for cardiovascular disease, which is more pronounced in women than in men.     

Association of the lipoprotein lipase and Apolipoprotein C-II gene polymorphisms with risk of dyslipidemia in smokers and non-smokers male

ObjectiveDyslipidaemia is considered a metabolic abnormality andan important risk factor that leads to atherogenic cardiovascular diseases. Cigarette smoking is associated with dyslipidaemia. This study aimed to demonstrate whether lipoprotein lipase enzyme (LPL) and Apolipoprotein CII (APOCII) gene polymorphisms can be considered as independent genetic risk factors for dyslipidaemia among smokers with various smoking durations.MethodsA total of 185 males (90 smokers and 95 non-smokers)were included in this study, Lipid profiles were measured and DNA was isolated. The LPL-Hind III and APO CII-Ava II polymorphisms were determined using the polymerase reaction-restriction fragment length polymorphisms (RFLP) technique.ResultsFor the LPL-Hind IIIpolymorphism H+H+ genotype group, the triglycerides TG and very-low-density lipoprotein cholesterol VLDL-C concentrations were significantly higher and the high-density lipoprotein cholesterol HDL-C concentration was significantly lower than those of the H–H- genotype. ForAPO CII-Ava II polymorphisms, compared with those of the A2A2 genotype group, the total cholesterol TC, TG, low-density lipoprotein cholesterol LDL-C and VLDL-C concentrations were significantly increased in the A1A2 genotype group, while the HDL-C concentration was significantly decreased.ConclusionsThe study revealed that the H+H+ or H + H-genotype of the LPL-Hind III polymorphism and the A1A1or A1A2 genotype of the APOCII-Ava II polymorphism were at higher risk of developing dyslipidaemia compared to the H–H- genotype of the LPL-Hind III polymorphism and A2A2 genotype of the APOCII-Ava II polymorphism.     

Age-distribution, risk factors and mortality in smokers and non-smokers with acute myocardial infarction: a review. TRACE study group. Danish Trandolapril Cardiac Evaluation.

Smoking is a risk factor for acute myocardial infarction; paradoxically, many studies have shown a lower post-infarct mortality among smokers. There are some important differences between smokers and non-smokers, which might explain the observed difference in mortality: smokers have less multivessel disease and atherosclerosis but are more thrombogenic; thrombolytic therapy seems to be more effective among smokers; smoking might result in an increased out-of-hospital mortality rate, by being more arrhythmogenic; and smokers are on average a decade younger than non-smokers at the time of infarction, and have less concomitant disease. Adjusting for these differences in regression analyses shows that smoking is not an independent risk factor for mortality after acute myocardial infarction. The difference in age and risk factors are responsible for the lower mortality among smokers.     

Hypopituitary females have a high incidence of cardiovascular morbidity and an increased prevalence of cardiovascular risk factors

We recently reported that female patients with hypopituitarism receiving controlled thyroid and steroid hormone substitution, but without GH replacement, had a more than 2-fold increase in cardiovascular mortality compared to the general population. In the present study we investigated the incidence of cardiovascular disease as well as the prevalence of cardiovascular risk factors in 33 females with hypopituitarism for 6-46 yr (median, 18) compared to those in 33 control subjects recruited from the general population in the same geographical area and matched for sex, age, smoking habits, educational level, and residence location. The patients were with a very high probability GH deficient, as 29 had subnormal serum insulin-like growth factor I levels, and the other 4 were GH deficient, as assessed by an insulin tolerance test. The incidence of cardiovascular disease was significantly higher among the hypopituitary patients (incidence ratio, 3.7; 95% confidence interval, 1.2-11.3), and the consumption of cardioactive drugs was also significantly higher (P = 0.002). Hypopituitary patients had a lower degree of physical exercise during their spare time (P = 0.02), a higher waist/hip ratio (P = 0.01), lower high density lipoprotein cholesterol (P = 0.002), and higher low density/high density lipoprotein ratio (P = 0.009). Furthermore, the patients had a significantly increased left atrium size (P = 0.05), but no difference was observed for other cardiac measures. In the patients, serum insulin-like growth factor I levels significantly correlated with left ventricular mass index (r = 0.48; P = 0.006), suggesting that GH has a strong impact on cardiac size. More episodes of bradycardia (P = 0.05), but no increased occurrence of extrasystolies, were encountered in the patients during 24-h continuous electrocardiogram monitoring. Carotid artery intima-media thickness and plaque numbers did not differ between patients and controls. In conclusion, hypopituitary females exhibit an increased incidence of cardiovascular disease, higher cardioactive drug consumption, and an increased prevalence of cardiovascular risk factors. The increased cardiovascular morbidity could not be ascribed to inadequate estrogen or thyroid hormone treatment, and unsubstituted GH deficiency is probably an important contributing factor.     

Orlistat and cardiovascular risk profile in hypertensive patients with metabolic syndrome: the ARCOS study

Weight loss improves metabolic abnormalities and reduces cardiovascular risk in obese hypertensive patients. To evaluate the impact of a sustained weight loss on coronary risk, 181 hypertensive patients with metabolic syndrome underwent to orlistat therapy, 120 mg, t.i.d., plus diet for 36 weeks. During therapy, Framingham risk scores (FRS) were calculated for determination of coronary heart disease risk in ten years. Body mass index decreased from 35.0 +/- 4.2 to 32.6 +/- 4.5 kg/m(2) (p< 0.0001) and waist circumference from 108.1 +/- 10.1 to 100.5 +/- 11.1 cm (p< 0.0001), at the end of the study period (week 36). Systolic and diastolic blood pressure showed reductions after the two first weeks, which were maintained up to the end of the study. A clear shift to the left in FRS distribution curve occurred at the end of the study, compared to baseline, indicating a reduction in coronary risk. Over all patients at risk, 49.2% moved to a lower risk category. A weight loss > 5% occurred in 64.6% of all patients, associated with improvement in glucose metabolism. Among those with abnormal glucose metabolism, 38 out 53 patients (71.7%) improved their glucose tolerance (p< 0.0005). In conclusion, long-term orlistat therapy helps to reduce and maintain a lower body weight, decreasing risk of coronary disease and improving glucose metabolism, thus protecting against type 2 diabetes.