Circulation November 8, 2016 Issue

 


Dr. Carolyn Lam:


 


 


 


 


 


 
Welcome to circulation on the run. Your weekly podcast summary
and backstage pass to the journal and its editors. I'm Dr.
Carolyn Lam associate editor for the National heart center and
Duke National University of Singapore. Our podcast is really
going around the world, and today's feature interview comes to
you live from China. Where we will be discussing the prediction
of ten year risks of cardiovascular disease in the Chinese
population. So now to all our Chinese colleagues out there:
Chinese dialect


 
 
First here's your summary of this week's journal. The first study
challenges the assumption that all patients with vascular disease
are at high risk of recurrent vascular events. First author Dr.
Kasenbrud corresponding author Dr. Viceren and colleagues form
the University Medical center Utric in the Netherlands, provide
new data on the estimation of ten year risk of recurrent vascular
events and a secondary prevention population. In other words, in
patients with established cardiovascular disease they applied the
second manifestations of arterial disease or 'smart' score for
the ten year risk prediction of myocardial infarction, stoke or
vascular death in more than six thousand-nine hundred Dutch
patients with vascular diseases ranging for coronary artery
disease, cerebral-vascular disease, peripheral artery disease,
abdominal aortic aneurysm and poly-vascular disease. Predictors
included in the SMART risk score included age, sex, current
smoking, diabetes, systolic blood pressure, total cholesterol,
HGL cholesterol, presence of coronary artery disease,
cerebral-vascular disease, peripheral artery disease, abdominal
aortic aneurysm, estimated glomariaol fruition rate, high
sensitivity CRP and years since the first manifestation of
vascular disease. They further externally validated the risk
score in more than eighteen thousand four hundred patients with
various types of vascular disease fro the TNT ideals Sparkle and
Capri trials.


 
 
The overall findings was that the external performance of the
SMART risk score was reasonable apart from over-estimation of
risk in patients which a ten year risk of more than forty
percent. What was striking was the substantial variation in the
estimated ten year risk. The median ten year risk of a
reoccurring major vascular event was 17 percent but this varied
for less than 10 percent in 18 percent to more than 30 percent in
22 percent of patients.


 
 
The authors further estimated residual risk at guideline
recommend targets by applying the relative risk reductions form
meta-analysis to estimated risks for targets for systolic
pressure, LDL, smoking, physical activity and use of
anti-thrombotic agents. They found that if all modifiable risk
factors were at guideline recommend targets only half of the
patients would have ten year risk of less than 10 percent. Even
with optimal treatment many patients with vascular disease appear
to remain at more than a 20 percent or even more than 30 percent
of a ten year risk.


 
 
The take home message is that a single secondary prevention
strategy for all patients with vascular disease may not be
appropriate. Instead novel risk stratification approaches may be
helpful to individualize secondary prevention by identifying high
risk patient which may derive the greatest benefit from novel
interventions.


 
 


 


 


 


 


 


 


 


 


 
The next study provides experimental evidence that an
indigenous-gastro transmitter hydrogen sulfide may potentially be
a therapeutic target in diabetic patients with cardiovascular
diseases. In this paper by first author Dr. Chen, corresponding
author Dr.Kisher and Colleagues from the Louis Cat's school of
medicine Temple University in Philadelphia. Authors aim to
evaluate the role of hydrogen sulfide deficiency in diabetes
induced bone marrow cell dysfunction and to examine the
therapeutic effects of restoring hydrogen sulfide production in
diabetic bone marrow cells on ischemic high limb injury in
diabetic DBDB mice. They further specifically investigated the
effects of hydrogen sulfide deficiency on the nitric oxide
pathways under conditions of high glucose. They found that bone
marrow cells for diabetic DBDB mice had decreased hydrogen
sulfide production and lower levels cystathonine gamma lyaze
which is the primary enzyme that produces hydrogen sulfide in the
cardiovascular system. Administration of a stable hydrogen
sulfide donor and over expression of cystathonine gamma lyaze in
diabetic bone marrow cells restore their functional and
restorative properties. Further more they demonstrated that the
therapeutic actions of hydrogen sulfide were mediated by nitric
oxide pathway involving endothelial nitric oxide synthase PT495.


 
 
In summary these results support the hypothesis that hydrogen
sulfide deficiency plays critical role in diabetes induced bone
marrow cell dysfunction and suggests that modulating hydrogen
sulfide production in diabetic bone marrow cells may have
transformational value in treating critical limbs ischemia.


 
 
The next study reinforces the importance of hypertension as a
critical risk factor for inter-cerebral hemorrhage, and suggests
that Blacks and Hispanics may be a particularly high risk. In
this study by DR. Walsh and colleagues for the University of
Cincinnati, authors conducted the largest case controlled study
to date on treated and untreated hypertension as a risk factor
for inter-cerebral hemorrhage. They also investigated whether
there was variation by ethnicity. The ethnic racial variations of
inter-cerebral hemorrhage or eriche study is a prospective
multi-center case controlled study of inter-cerebral hemorrhage
among Whites, Blacks and Hispanics. Cases were enrolled from 42
recruitment cites, controls were matched cases one to one by age,
sex, ethnicity and metropolitan area. A total of 958 white, 880
black and 766 Hispanic cases of inter-cerebral hemorrhage were
enrolled. Untreated hypertension was more highly prevalent in
Blacks at almost 44 percent and Hispanics at almost 47 percent
compared to whites at 33 percent. Treated hypertension was a
significant independent risk factor and untreated hypertension
was substantially greater risk factor for all three ethnic groups
and across all locations. There was a striking interaction
between ethnicity and risk of inter-cerebral hemorrhage, such
that untreated hypertension conferred a greater risk of
inter-cerebral hemorrhage in Blacks and Hispanics relative to
Whites.


 
 


 


 


 


 


 


 


 


 


 


 
The nest study provides the first prospective multi-centered data
on mortality and morbidity in rheumatic heart disease from low
and middle income countries. First author Dr. Zulky,
corresponding author Dr. Mayoci and authors from Gertrude
hospital and University of Cape Town in South Africa present the
results of two year follow up of the global rheumatic heart
disease registry or remedy study in 3343 children and adults with
rheumatic heart disease from 14 low and middle income countries.
They found that although patients were young with a median age of
only 28 years the 2 year case fatality rate was high at almost 17
percent. The median age at death was 28.7 years. Mortality was
higher in low income and low middle income regions compared to
upper middle income countries. Independent predictors of death
was severe valve disease, more advanced functional class, atrial
fibrillation and older age. Where as post primary education and
female sex were associated with a lower risk of death. The
authors carefully noted that apart from age and gender the
independent risk factors for mortality such as severity of valve
disease heart failure, atrial fibrillation and low education were
all modifiable and thus they called for programs focused on the
early detection and treatment on clinical rheumatic heart
disease.


 
 
Well that's it for the summaries, now lets go over to China


 
 
For our feature interview today we are going all the way to
Beijing at the great Wall meeting where we will be meeting
authors as well as editors. So here we have first and
corresponding author Professor {Dong Fen Gu} and co-author
Professor {Sherliang} both from {Fu Y} hospital Chinese academy
of medical sciences in Beijing. Welcome


 
Dr.Gu:
Welcome we are so delighted to be interviewed by you


 
Dr. Carolyn Lam:


 
Thank you so much we are so excited to be talking about your
paper predicting the ten year risks of cardiovascular disease in
the Chinese population. And here we have as well editor in chief
Dr. Joe Hill as well as Dr. Amid Kira digital strategies editor
and associate editor. Gentlemen how is it in Beijing? And I hear
that you have a Chinese greeting for everyone as well.


 
Joe Hill:
{Ni how} and {nuchme and senchmen}


 
Amid Kira:
I can't top that but I agree with what Joe said


 
Dr. Carolyn Lam:
Dr. Gu, could you please tell us what is it that is so different
about cardiovascular disease in China compared to what we heard
about in the western world.


 
Dr.Gu:
Okay cardiovascular disease is both leading cause of death in
China and in United States as well in European countries. However
the patterns for components of cardiovascular disease including
coronary arteries and stroke are still quite different in the
Chinese populations compared united states. For example there are
coronary arteries mortality rate in the united states is along
the 100 thousand per year and this is the first leading cause of
death in the united states. And for stroke the annual mortality
rate is along 36 per 100 thousand in the united states
populations. However in china the stroke mortality rate among
Chinese populations is around the 160 per 100 thousand, so that
almost 3.5 to 4 as high as in untied states. Obviously for our
lifestyle in including battery behavior quite different you can
easily identify one kind of difference in the united states and
the Europe restaurants from Chinese restaurants and some western
style restaurants you can figure it out.


 
 


 


 


 


 
And another example, smoking rate is major component for risk of
cardiovascular disease it is very high in Chinese adult men. It
over 50 percent right now but in the united states in the past 50
years it declined immensely. And around maybe less than around 20
percent and from the previous experiment from studies by Dr. Liu
Chin from and my colleague Dr.WU they used the questions for
predictions of coronary arteries compared to equations and also
use the similar prediction model compares that its chemical
cardiovascular disease from the united states population and the
Chinese population. That to over estimation if we use the united
states produced this kind of equation. So based on this kind of
scenario we based on Chinese long term larger scales cohort to
precede and study our own prediction model.


 
Dr. Carolyn Lam:
Wow that is really fascinating Dr. Gu and I really could not
agree with you more because I sort of trained in the united
states for quite some time and then I moved back to Singapore and
saw for myself in Asia the tremendously high rates of stroke. I
was also very struck by the relative youth of the patients
suffering cardiovascular disease and the differences in risk
factors, the smoking but not just that, obesity is almost defined
on a different scale in our relatively sized smaller Chinese
population compared to that in the western. Congratulations to
you and your team for a successful amazing effort. Could you or
Dr. Yang now just let us know what are your main findings.


 
Dr. Yang:


 


 


 


 


 
Well I think there are 2 major finding for our work. First we
developed a new prediction risk model you know after analysis is
for high risk score or equations released by AJ and ACC and is
some other risk scores. We included 6 conditional risk factors in
combination with our previous knowledge that included age,
treated or untreated ISBP, total classical, HDLC current smoking
and diabetes. So this traditional risk factors were set up as a
base model and then we use the predefined statistical to include
new additional variables they were Chinese special elements.
Finally in our model there were rates as constraints and
geographic region which means northern part versus the southern
part in China and also organization is rural or urban area. And
finally the forth one is family history as a CVD so this for
additional variables in our model suggest that we maybe as a
Chinese prediction and equations has something special. For
example we feel more attention for central obesity in primary
prevention in Chinese populations and also you know the norther
part and the southern part there are large differences in the
risk profiles. And so maybe according to our risk prediction
model we pay more attentions for the residence living in northern
part in China.


 
 
And then for the second points I think we found that PCE equation
which shows for equations was not appropriate to predict ten year
risk of in Chinese populations. For example in our revelation
cohort we found that our model just slightly over predicts
severity risk by 17 percent in Chinese man but when we use the
PCE models released form AHA the over-estimation come to 50
percent so maybe equations from western populations are not
appropriate to Chinese populations.


 
Dr. Carolyn Lam:
Thank you so much Dr. Yang I mean those are just such important
findings applicable to a huge population in china, like you said.
And just as important as the second point that the pooled
equations derived from western populations may not be the most
appropriate for certain other ethnic populations. I think that a
very important message and that why we are so proud to be
publishing this in Circulation. Could I ask then are you applying
these new equations in your personal clinical practice?


 
Dr.Gu:


 
Risk assessment is a fundamental components for prevention of
ASSVD. In Chinese we question {turn the PA on} provide a valuable
to identify high risk individuals in Chinese populations. And not
with just complicated [inaudible 00:18:02] for further analysis.
And propose three levels of groups of risk stratification could
be identified by cut off 5 percent and 10 percent. So lower risk
individuals with predicted activity risk of less than 5 percent
should be offered lifestyle wise to maintain the lower risk
status. While the moderate risk individual is predicted risk of 5
to 10 percentage for intensive therapeutic lifestyle change wit
drug therapy if necessary. For the high individual risk high or
large 10 percent teheraph of clinical aliment taken account for
physicians recommendation should be required with therapy for the
lifestyle modification. Then annually clinic up, including an
echocardiographic information for carotid artery back and even
for outer [inaudible 00:19:09] CT examinations for coronary
artery are recommended. Also blood pressure, lipids, glucose
measurement if necessary are suggest according to Chinese
guideline. While cardiovascular disease prevention as well as for
the epidemic of this kind a lines. For ACVD patients those are
different kinds of risk assessment we could know whether their
risk profile had been improved or be progressed so that
appropriate clinical elements should be taken in clinical
practice.


 
Dr. Carolyn Lam:
Thank you very much Dr. Gu so that just show that these findings
are immediately clinically applicable and I trust that means
you're suing it in your clinics too, and once again were so happy
to be publishing this in Circulation so in the rest of the time
in going to now direct questions at Joe and Amid.


 
 
How's China been? How are your chopstick skills and any word on
how Circulation is being received there?


 
Joe Hill:
Well Carolyn its a delight to be here this is a bustling media
that get better and better every year. In about 2 hours we have
our first ever Circulation session, we brought several editors
here to discuss the types of content that we are looking to
publish, the type of work across prevention and population and
electrophysiology of heart failure. This is an extraordinary
media that is now internationally acclaimed and as we've heard
here, the face of cardiovascular disease in Asia is changing. And
as you pointed out 60percent of the human race lives in Asia and
we want to do everything we can to be here on the ground, in Asia
trying to address this curve that is already present and is
worsening by the day.


 
Dr. Carolyn Lam:
Amid, you know you've seen the latest statistic on our podcasts
and you highlighted that we have quite a number of listeners over
there as well. Would you like to tell me how this is all blending
it to the digital strategies and anything else you might want to
highlight?


 
Amid Kira:
Sure its been an incredible meeting and we get to meet great
colleagues like our colleagues today on this podcast and learning
so much from this meeting. Our podcast as you pointed out quite a
sizable and growing cadre of people in Asia and Japan and China
who are listening and we truly want to enhance that as Joe
mentioned with the large splurge of cardiovascular disease and
the great science that is going on here. Want to make sure that
we are able to be apart of that conversation and interact with
researcher and clinitions here. In addition to podcast, we are
exploring some other options involving social media, specifically
in China so stayed tuned in how those develop but we certainly
appreciate the importance of being her and interacting where so
much of cardiovascular disease and cardiovascular science is
occurring.


 
Dr. Carolyn Lam:
That's so great. Joe or Amid now there's a specific we would like
to highlight to our listeners the doodle, either of you want to
pick that up a bit about blipping the doodle?


 
Amid Kira:
So there is as you know Circulation now has this doodle where we
change it periodically and its sort of a fun themed thing. Right
now I think it Halloween and we've had several other ones that
people have designed to sort of keep thing fresh and light and
interesting. There's a new app called blippar which you can
download from iTunes or android stores and you can essentially
scroll that over with your phone with the doodle and that will
take you to new content either table of contents of videos,
different kinds of content that it can navigate you to. So I hope
people will not only enjoy the doodle kind of anticipate what's
next in terms of seasons but will take the time t blip the doodle
when they get a chance.


 
Dr. Carolyn Lam:
That great and that blippar- B l I P P A R. You really c should
check it out, anyone who is listening to this really check it out
you'll be floored. Joe could I just turn the mic to you for any
last words about the global outreach of Circulation, I mean its
just so amazing that you're there in China


 
Joe Hill:
Well heart disease Carolyn knows no boundaries nor does
Circulation. There was a day when cardiovascular disease was
largely an issue in the developed world that is long since gone
and that's why the study that we are talking about today with
these authors is so important because the face of cardiovascular
disease is different than in the west, the ways in which it
is  evolving id different here than in the west and I like
many others foresee an increase a significant increase in the
types and prevalence of heart disease here in Asia. for all the
reasons that we have been talking about, hypertension, obesity,
type two diabetes, smoking the environment all of these
challenges I fear are going to lead to a substantial increase in
the prevalence of heart disease in Asia and that why we're here
on the ground with Circulation in Asia that's why we have one of
our major leaders Chong Shong Ma who is here in Beijing.
Circulation is in China everyday, it’s in Beijing everyday to try
and address this problem.


 
Dr. Carolyn Lam:
And you heard it from our editor and chief, so thank you everyone
for listening to this episode of Circulation on run. Tune in next
week.