Nov 7, 2016
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.