Despite good control of all risk factors for myocardial infarction, including blood glucose, blood pressure, lipids, and smoking, the probability of heart failure is significantly higher in diabetic patients than in healthy individuals. This observational study shows that the current treatment guidelines, which focus on the prevention of myocardial infarction, are insufficient in preventing heart failure development. Now, understanding the mechanisms of heart failure in diabetic patients and developing treatment guidelines based on these mechanisms are urgently needed. Instead of narrowly viewing that heart failure is caused by poor cardiac function, we need to take a bird's-eye view that heart failure is caused by a shift in the hemodynamic set point (blood pressure, heart rate, circulating blood volume, and autonomic balance) toward overloading the heart due to the persistent drive of the pathological kidney-brain-heart coupling. Clinical evidence, which shows that sodium-glucose-coupled transporter [Na＋/glucose co-transporter (SGLT)-2] inhibitors slowed the progression of chronic kidney disease (CKD) and reduced heart failure hospitalizations and deaths, underscores the importance of the renocardiac syndrome in heart failure development in diabetic patients.
Arterial stiffness is recognized mainly as an indicator of arteriosclerosis and a predictor of cardiovascular events. Cardio-ankle vascular index (CAVI), which reflects arterial stiffness from the origin of the aorta to the ankle, was developed in 2004. An important feature of this index is the independency from blood pressure at the time of measurement. A large volume of clinical evidence obtained using CAVI has been reported. CAVI is high in patients with various atherosclerotic diseases including coronary artery disease and chronic kidney disease. Most coronary risk factors increase CAVI and their improvement reduces CAVI. Many prospective studies have investigated the association between CAVI and future cardiovascular disease (CVD), and proposed CAVI of 9 as the optimal cut-off value for predicting CVD. Research also shows that CAVI reflects afterload and left ventricular diastolic dysfunction in patients with heart failure. Furthermore, relatively acute changes in CAVI are observed under various pathophysiological conditions including mental stress, septic shock and congestive heart failure, and in pharmacological studies. CAVI seems to reflect not only structural stiffness but also functional stiffness involved in acute vascular functions. In 2016, Spronck and colleagues proposed a variant index CAVI0, and claimed that CAVI0 was truly independent of blood pressure while CAVI was not. This argument was settled, and the independence of CAVI from blood pressure was reaffirmed. In this review, we summarize the recently accumulated evidence of CAVI, focusing on the proposed cut-off values for CVD events, and suggest the development of new horizons of vascular function index using CAVI.
Aim: N-terminal pro-B-type natriuretic peptide (NT-proBNP), frequently used as a biochemical marker for detecting and monitoring heart failure, is also a risk marker for development of coronary heart disease and total stroke. However, studies that explore subtypes of ischemic stroke with regard to NT-proBNP are scarce. Here, we examined NT-proBNP and its impact upon subtypes of ischemic stroke (lacunar stroke, large-artery occlusive stroke and embolic stroke) among Japanese.
Methods: We measured NT-proBNP and categorized 4,393 participants of the Circulatory Risk in Communities Study into four groups (＜55, 55-124, 125-399, and ≥ 400 pg/ml). We used a multivariable Cox proportional hazards model to examine association with risks of stroke and subtypes.
Results: During 4.7 years of follow-up, we identified 50 strokes, including 35 ischemic (15 lacunar, 6 largeartery occlusive, 10 embolic strokes) and 14 hemorrhagic strokes. NT-proBNP was associated with stroke risk: the multivariable hazard ratio of total strokes was 7.29 (2.82-18.9) for the highest and 2.78 (1.25-6.16) for the second highest NT-proBNP groups compared with the lowest group. The respective hazard ratios for the highest NT-proBNP group were 9.37 (3.14–28.0) for ischemic stroke and 6.81 (1.11–41.7) for lacunar stroke. Further adjustment for atrial fibrillation did not attenuate these associations. The associations were similarly observed for large-artery occlusive and embolic strokes.
Conclusion: We found that even moderate serum levels of NT-proBNP were associated with the risk of total and ischemic strokes among Japanese whose NT-proBNP levels were relatively low compared with Westerners.
Aim: The aim of the current study is to describe the presentation pattern of symptomatic peripheral artery disease undergoing endovascular therapy (EVT) in comparison to symptomatic coronary artery disease undergoing percutaneous coronary intervention (PCI) based on data from nationwide databases.
Methods: Data were extracted from the nationwide procedural databases of EVT and PCI in Japan (J-EVT and J-PCI) between 2012 and 2017. The presentation pattern was investigated using a Poisson regression model, including the month, seasonality, and weekend (versus weekday) as the explanatory variables. Seasonality was expressed as a cosine function of a 12-month period, and its significance was evaluated using the Fisher–Yates shuffle method.
Results: A total of 41,906 and 62,585 cases underwent EVT for critical limb ischemia (CLI) and intermittent claudication (IC), respectively, whereas 518,858 and 504,139 cases underwent PCI for acute coronary syndrome (ACS) and stable angina (SA). The procedural volume increased by 21.6%, 12.3%, 4.5%, and 3.6% per year in CLI, IC, ACS, and SA. CLI and ACS, but not IC or SA, showed a significant volume seasonality. Compared with ACS, CLI demonstrated a larger peak-to-trough ratio of seasonality (1.75 versus 1.21; P＜0.001), and a later peak appearance (February–March versus January–February by 1.37 months; P＜0.001). The procedural volume on weekends relative to weekdays was smaller for SA, IC, and CLI than for ACS. These distinct features were observed in a diabetic population and a non-diabetic population.
Conclusions: The current study analyzed nationwide procedural databases and demonstrated the presentation pattern of symptomatic PAD and CAD warranting revascularization.
Aim: Previous studies on peripheral artery disease (PAD) only enrolled patients with atherosclerotic lesion limited to any one of isolated locations (aortoiliac [AI], femoropopliteal [FP], and below the knee [BTK]). However, the interventions for PAD in a real-world clinical setting are often simultaneously performed for several different locations.
Methods: We conducted a prospective multicenter study that included 2,230 patients with PAD who received intervention for lower extremity lesions in each area and across different areas. Patients were divided into 7 groups according to the combination of treatment locations. Overall survival (OS), major adverse limb events (MALEs), and risk factors for OS and MALEs were statistically analyzed.
Results: After adjustment for confounding factors, the attributable risk for OS was similar among isolated AI, FP, and BTK treatments. MALEs increased in correlation with the number of treatment locations. Dialysis and critical limb ischemia were the common risk factors for OS and MALEs. However, the contribution of other factors such as type of drug usage was different according to treatment locations.
Conclusions: In patients with PAD, OS was largely defined by comorbidities but not by lesion location. The background risk factors, underlying comorbidities, and event rates were different according to PAD location, suggesting that stratified treatment should be established for different patient populations.
Aim: Inter-arm blood pressure difference (IAD) is known to be associated with a composite of cardiovascular disease (CVD) and with CVD risk factors. However, only limited information is available regarding the contribution of diabetes mellitus to IAD and the association of IAD with individual CVDs, such as coronary artery disease (CAD), stroke, and peripheral artery disease (PAD).
Methods: We addressed these issues in this cross-sectional study of 2580 participants who had simultaneous blood pressure measurements in both arms using an automated device.
Results: Compared with 1,264 nondiabetic subjects, 1316 patients with diabetes mellitus had a greater IAD (P=0.01) and a higher prevalence of IAD of ≥ 10 mmHg (8.4% vs. 5.4%, P=0.002). However, such difference was not significant after the adjustment for potential confounders. Among CAD, stroke, and PAD, only PAD was significantly associated with IAD in a model adjusted for the CVD risk factors. Age was found to modify the association between IAD and PAD, with the association being more prominent in the younger subgroup.
Conclusion: Thus, diabetes mellitus itself was not an independent factor associated with IAD. A larger IAD was preferentially associated with the presence of PAD, and this association was modified by age.
Aim: Coronary atherosclerotic plaques can be detected in asymptomatic subjects and are related to low-density lipoprotein cholesterol (LDL) levels in patients with coronary artery disease. However, researchers have not yet determined the associations between various plaque characteristics and other lipid parameters, such as HDL-C and TG levels, in low-risk populations.
Methods: One thousand sixty-four non-diabetic subjects (age, 57.86±9.73 years; 752 males) who underwent coronary computed tomography angiography (CCTA) were enrolled and the severity and patterns of atherosclerotic plaques were analyzed.
Results: Statin use was reported by 25% of the study population, and subjects with greater coronary plaque involvement (segment involvement score, SIS) were older and had a higher body mass index (BMI), blood pressure, unfavorable lipid profiles and comorbidities. After adjusting for comorbidities, only age (β=0.085, p＜0.001), the male gender (β=1.384, p＜0.001), BMI (β=0.055, p=0.019) and HbA1C levels (β=0.894, p＜0.001) were independent factors predicting the greater coronary plaque involvement in non-diabetic subjects. In the analysis of significantly different (＞50%) stenosis plaque patterns, age (OR: 1.082, 95% CI: 10.47-1.118) and a former smoking status (OR: 2.061, 95% CI: 1.013-4.193) were independently associated with calcified plaques. For partial calcified (mixed type) plaques, only age (OR: 1.085, 95% CI: 1.052-1.119), the male gender (OR: 7.082, 95% CI: 2.638-19.018), HbA1C levels (OR: 2.074, 95% CI: 1.036-4.151), and current smoking status (OR: 1.848, 95% CI: 1.089-3.138) were independently associated with the risk of the presence of significant stenosis in mixed plaques.
Conclusions: A higher HbA1c levels is independently associated with the presence and severity of coronary artery atherosclerosis in non-diabetic subjects, even when LDL-C levels are tightly controlled.
Aim: We sought to validate the 2010 Caprini risk assessment model (RAM) in risk stratification for deep vein thrombosis (DVT) prophylaxis among Chinese bedridden patients.
Methods: We performed a prospective study in 25 hospitals in China over 9 months. Patients were risk-stratified using the 2010 Caprini RAM.
Results: We included a total 24,524 patients. Fresh DVT was found in 221 patients, with overall incidence of DVT 0.9%. We found a correlation of DVT incidence with Caprini score according to risk stratification (χ2 =196.308, P＜0.001). Patients in the low-risk and moderate-risk groups had DVT incidence ＜0.5%. More than half of patients with DVT were in the highest risk group. Compared with the low-risk group, risk was 2.10-fold greater in the moderate-risk group, 3.34-fold greater in the high-risk group, and 16.12-fold greater in the highest-risk group with Caprini scores ≥ 9. The area under the receiver operating characteristic curve was 0.74 (95% confidence interval, 0.71–0.78; P＜0.01) for all patients. A Caprini score of ≥ 5 points was considered the criterion of a reliably increased risk of DVT in surgical patients with standard thromboprophylaxis. Predicting DVT using a cumulative risk score ≥ 4 is recommended for nonsurgical patients.
Conclusions: Our study suggested that the 2010 Caprini RAM can be effectively used to stratify hospitalized Chinese patients into DVT risk categories, based on individual risk factors. Classification of the highest risk levels using a cumulative risk score ≥ 4 and ≥ 5 provides significantly greater clinical information in nonsurgical and surgical patients, respectively.
Background: Peripheral artery disease (PAD) is the most underdiagnosed, underestimated and undertreated of the atherosclerotic vascular diseases despite its poor prognosis. There may be racial or contextual differences in the Asia-Pacific region as to epidemiology, availability of diagnostic and therapeutic modalities, and even patient treatment response. The Asian Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) thus coordinated the development of an Asia-Pacific Consensus Statement (APCS) on the Management of PAD.
Objectives: The APSAVD aimed to accomplish the following: 1) determine the applicability of the 2016 AHA/ACC guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease to the Asia-Pacific region; 2) review Asia-Pacific literature; and 3) increase the awareness of PAD.
Methodology: A Steering Committee was organized to oversee development of the APCS, appoint a Technical Working Group (TWG) and Consensus Panel (CP). The TWG appraised the relevance of the 2016 AHA/ACC PAD Guideline and proposed recommendations which were reviewed by the CP using a modified Delphi technique.
Results: A total of 91 recommendations were generated covering history and physical examination, diagnosis, and treatment of PAD—3 new recommendations, 31 adaptations and 57 adopted statements. This Asia-Pacific Consensus Statement on the Management of PAD constitutes the first for the Asia-Pacific Region. It is intended for use by health practitioners involved in preventing, diagnosing and treating patients with PAD and ultimately the patients and their families themselves.