Showing papers by "Anushka Patel published in 2005"

Smoking, quitting, and the risk of cardiovascular disease among women and men in the Asia-Pacific region.

Abstract: Published by Oxford University Press on behalf of the International Epidemiological Association © The Author 2005; all rights reserved.

Associations of Inflammatory and Hemostatic Variables With the Risk of Recurrent Stroke

Abstract: Background and Purpose— Several prospective studies have shown significant associations between plasma fibrinogen, viscosity, C-reactive protein (CRP), fibrin d-dimer, or tissue plasminogen activat...

Associations of inflammatory and hemostatic variables with the risk of recurrent stroke: a nested case control study

Abstract: Background and Purpose— Several prospective studies have shown significant associations between plasma fibrinogen, viscosity, C-reactive protein (CRP), fibrin d-dimer, or tissue plasminogen activator (tPA) antigen and the risk of primary cardiovascular events. Little has been published on the associations of these variables with recurrent stroke. We studied such associations in a nested case-control study derived from the Perindopril Protection Against Recurrent Stroke Study (PROGRESS). Methods— Nested case-control study of ischemic (n=472) and hemorrhagic (n=83) strokes occurring during a randomized, placebo-controlled multicenter trial of perindopril-based therapy in 6105 patients with a history of stroke or transient ischemic attack. Controls were matched for age, treatment group, sex, region, and most recent qualifying event at entry to the parent trial. Results— Fibrinogen and CRP were associated with an increased risk of recurrent ischemic stroke after accounting for the matching variables and adjusting for systolic blood pressure, smoking, peripheral vascular disease, and statin and antiplatelet therapy. The odds ratio for the last compared with the first third of fibrinogen was 1.34 (95% CI, 1.01 to 1.78) and for CRP was 1.39 (95% CI, 1.05 to 1.85). After additional adjustment for each other, these 2 odds ratios stayed virtually unchanged. Plasma viscosity, tPA, and d-dimer showed no relationship with recurrent ischemic stroke, although tPA was significant for lacunar and large artery subtypes. Although each of these variables showed a negative relationship with recurrent hemorrhagic stroke, none of these relationships achieved statistical significance. Conclusions— Fibrinogen and CRP are risk predictors for ischemic but not hemorrhagic stroke, independent of potential confounders.

Prediction of Myocardial Infarction by N-Terminal-Pro-B-Type Natriuretic Peptide, C-Reactive Protein, and Renin in Subjects With Cerebrovascular Disease

Abstract: Background— B-type natriuretic peptide (BNP), C-reactive protein (CRP), and renin are elevated in persons at risk for cardiovascular disease. However, data that directly compare these markers in the prediction of myocardial infarction (MI) are limited. Methods and Results— N-terminal-proBNP (NT-proBNP), CRP, and renin were measured in baseline blood samples from a nested case-control study of the 6105 participants of the Perindopril Protection Against Recurrent Stroke Study (PROGRESS), a placebo-controlled study of a perindopril-based blood pressure-lowering regimen among individuals with previous stroke or transient ischemic attack. Each of 206 subjects who experienced MI, either fatal or nonfatal, during a mean follow-up of 3.9 years was matched to 1 to 3 control subjects. Most MI cases (67%) occurred in subjects without a history of coronary heart disease. NT-proBNP, CRP, and renin each predicted MI; the odds ratio for subjects in the highest compared with the lowest quarter was 2.2 (95% CI, 1.3 to 3.6...

ADVANCE Action in Diabetes and Vascular Disease: patient recruitment and characteristics of the study population at baseline

Abstract: Aims The primary aim of ADVANCE is to determine the effects on macrovascular and microvascular disease of blood pressure lowering (with an ACE inhibitor–diuretic combination), irrespective of initial blood pressure level; and of intensive glucose lowering, in high-risk individuals with Type 2 diabetes. Methods The study is a 2 × 2 factorial randomized controlled trial. Following 6 weeks on active perindopril–indapamide combination, eligible participants were randomized to perindopril/indapamide (initially 2.0/0.625 mg daily, increasing to 4.0/1.25 mg daily after 3 months) or matching placebo; and to an intensive gliclazide MR-based glucose control regimen aiming for a haemoglobin A1c (HbA1c) value of 6.5% or lower, or local standard therapy. The study is being conducted in 215 centres in 20 countries within Australasia, Asia, Europe and North America. Results Recruitment commenced in June 2001 and was completed in March 2003, with the inclusion of 11 140 randomized participants. Fifty-seven per cent of participants are male and the mean age at baseline was 66 years. On average, the diagnosis of diabetes was made 8 years before study entry. At baseline 32 and 10% of patients had a history of macrovascular and microvascular disease, respectively. The mean blood pressure at baseline was 145/81 mmHg; the mean HbA1c concentration was 7.5%. While blood pressure and HbA1c values were broadly similar, certain characteristics of randomized participants varied between countries. Conclusions With successful worldwide recruitment completed, ADVANCE should provide reliable and broadly generalizable results on the effects of routine blood pressure lowering and intensive glucose control in high-risk individuals with Type 2 diabetes.

ADVANCE: action in diabetes and vascular disease.

Abstract: The burden of Type II diabetes is growing rapidly worldwide, across high-, middle- and low-income countries. This burden is associated primarily with increased risks of macrovascular and microvascular diseases, and it is agreed that multifactorial treatment regimens are required to reduce it. ADVANCE (Action in Diabetes and Vascular disease: Preterax and Diamicron-MR Controlled Evaluation) is a large-scale, 2 x 2 factorial, randomised clinical trial. It will investigate the potential benefits of blood pressure lowering, using a fixed low-dose combination of perindopril and indapamide vs placebo, and of tighter glucose control, using an intensive gliclazide-MR-based glucose control regimen vs a standard guidelines-based regimen, separately and together. The two primary outcomes are a composite macrovascular end point of nonfatal stroke, nonfatal myocardial infarction and cardiovascular death; and a composite microvascular end point of new or worsening nephropathy or microvascular eye disease. Following successful recruitment and randomisation of 11,140 participants by March 2003, the study is currently half way through its planned follow-up of 4.5 years. Adherence to randomised study treatment is good; and loss to follow-up is minimal. It is hoped that the study will answer a number of unresolved issues. The blood pressure lowering arm will investigate the possible reduction in major vascular disease in patients with Type II diabetes whether or not they have hypertension, and the possible benefits of blood pressure lowering in such patients already receiving background therapy with the ACE inhibitor perindopril. The glucose control arm will investigate the possible reduction in both macrovascular and microvascular disease achieved with tighter glucose control, targeting an HbA1c of 6.5% and a fasting blood glucose of 6.0 mmol/l. Finally, the factorial design will enable investigation of the combined effects of more intensive glucose control and tighter control of blood pressure.

Plasma lipids predict myocardial infarction, but not stroke, in patients with established cerebrovascular disease

Abstract: Aims To evaluate the role of plasma lipids in recurrent vascular events, including stroke, among individuals with established cerebrovascular disease. Methods and results Plasma total cholesterol, HDL cholesterol, and triglycerides were measured at baseline among individuals participating in the Perindopril Protection Against Recurrent Stroke (PROGRESS) study, a randomized clinical trial of blood pressure lowering among patients with previous stroke or transient ischaemic attack. A series of nested case–control studies were used to investigate the association between each of these lipid variables and the risk of subsequent haemorrhagic stroke, ischaemic stroke, myocardial infarction (MI), and heart failure. A total of 895 patients were selected as cases (83 haemorrhagic stroke, 472 ischaemic stroke, 206 MI, and 258 heart failure) and each was matched with one to three controls. After adjustment for other major cardiovascular risk factors, none of the lipid variables was associated with the risk of either stroke subtype. There were significant positive and negative associations for total cholesterol and HDL, respectively, with the risk of MI; the odds ratio comparing the highest and lowest thirds of each of these lipid variables was 2.00 (95% CI: 1.30–3.09) for total cholesterol and 0.58 (95% CI: 0.37–0.90) for HDL. HDL was inversely associated with the risk of heart failure; however, this result was of borderline statistical significance ( P =0.05). Conclusion Lipid variables are associated with the risk of MI, but not recurrent stroke, in patients with established cerebrovascular disease.

Prediction of Heart Failure by Amino Terminal-pro–B-Type Natriuretic Peptide and C-Reactive Protein in Subjects With Cerebrovascular Disease

Abstract: B-type natriuretic peptide (BNP) and C-reactive protein (CRP) are elevated in persons at risk for congestive heart failure (CHF). However, limited data are available directly comparing BNP-related peptides and CRP in persons at risk of CHF. To evaluate amino terminal-pro-BNP (NT-proBNP) and CRP, separately and together, for assessment of risk of CHF, we performed a nested case-control study of the 6105 participants of the Perindopril pROtection aGainst REcurrent Stroke Study (PROGRESS), a placebo-controlled study of a perindopril-based blood pressure-lowering regimen among individuals with previous stroke or transient ischemic attack (TIA). Each of 258 subjects who developed CHF resulting in death, hospitalization, or withdrawal of randomized therapy during a mean follow-up of 3.9 years was matched to 1 to 3 control subjects. NT-proBNP and CRP predicted CHF; the odds ratio for subjects in the highest compared with the lowest quarter was 4.5 (95% confidence interval, 2.7 to 7.5) for NT-proBNP and 2.9 (confidence interval, 1.9 to 4.7) for CRP, and each remained a predictor of CHF after adjustment for all other predictors. Screening for both markers provided better prognostic information than screening for either alone. Elevation of NT-proBNP above 50 pmol/L and CRP above 0.84 mg/L predicted CHF with sensitivity of 64% and specificity of 66%. NT-proBNP and CRP predicted CHF in subjects receiving perindopril-based therapy. We conclude that NT-proBNP and CRP are independent predictors of CHF risk after stroke or TIA. Moreover, NT-proBNP and CRP may be markers of mechanisms of CHF pathogenesis distinct from those responsive to angiotensin-converting enzyme inhibitor-based therapy.

Urinary albumin levels in the normal range determine arterial wall thickness in adults with Type 2 diabetes: a FIELD substudy

Abstract: Aim Cardiovascular disease (CVD) rates are substantially higher among patients with Type 2 diabetes than in the general population. The objective of this study was to identify the determinants of carotid intima media thickness (IMT) in patients with Type 2 diabetes. Methods We measured the thickness of the intima media layer of the carotid artery, a strong predictor of the risk of future vascular events, in 397 Type 2 diabetic patients drawn from the Fenofibrate Intervention and Event Lowering in Diabetes study, prior to treatment allocation. Results The mean IMT was 0.78 mm [interquartile range (IQR) 0.23 mm], and the maximum IMT was 1.17 mm (IQR 0.36 mm). By multivariate analysis, age, sex, duration of diabetes, triglycerides, and total cholesterol were independently correlated with IMT, as was urine albumin-creatinine ratio (ACR) (P 0.65 mg/mmol, approximately one-fifth the standard clinical threshold for microalbuminuria (P < 0.01). Long-term diabetes, independent of other parameters, was associated with a 50% increase in age-related thickening. Conclusions IMT in people with Type 2 diabetes is independently and continuously related to urine albumin levels and to the duration of diabetes. These results support previous data linking urine albumin measurements within the normal range with increased ischaemic cardiac mortality in the setting of Type 2 diabetes, and strongly suggest that urine albumin levels within this range should trigger a formal evaluation for CVD.

Does sex matter in the associations between classic risk factors and fatal coronary heart disease in populations from the Asia-Pacific region?

Abstract: ​​​​​​​Background: There is much interest in promoting healthy heart awareness among women. However, little is known about the reasons behind the lower rates of heart disease among women compared with men, and why this risk difference diminishes with age. Previous comparative studies have generally had insufficient numbers of women to quantify such differences reliably.Methods:We carried out an individual participant data meta-analysis of 39 cohort studies (32 from Asian countries and 7 from Australia and New Zealand). Cox models were used to estimate hazard ratios (HR) for coronary death, comparing men to women. Further adjustments were made for several proven coronary risk factors to quantify their contributions to the sex differential. Sex interactions were tested for the same risk factors.Results: During 4 million person-years of follow-up, there were 1989 (926 female) deaths from coronary heart disease (CHD). The age-adjusted and study-adjusted male/female HR (95% confidence interval [95% CI]) was 2.05 (1.89-2.22). At baseline, 54% of men vs. 7% of women were current smokers; hence, adjustment for smoking explained the largest component (20%) of this HR. A significant sex interaction was observed between systolic blood pressure (SBP) and CHD mortality such that a 10 mm Hg increase was associated with a 15% greater increase in the relative risk (RR) of coronary death in women compared with men (p = 0.002).Conclusions:Only a small amount of the sex differential in coronary death could be explained by differences in the prevalence of classic risk factors. Alternative explanations are required to explain the age-related attenuation of the sex difference in CHD risk.

Transient global amnesia following coronary angiography and angioplasty.

Abstract: We report two cases of transient global amnesia (TGA) after coronary catheterization. Although neurological disturbances after cardiac catheterization are uncommon, they do create grave concern. Neurological events associated with atheroembolism after cardiac catheterization often take the form of transient ischaemic attacks or strokes. TGA, however, has only been very rarely described to be associated with cardiac catheterisation. Patients with TGA present with anterograde and retrograde amnesia without any other neurological deficits. Anterograde amnesia refers to the inability to learn and form new memories. Retrograde amnesia refers to the loss of memory of the past from days up to years. TGA should be recognized as a rare complication after coronary angiography. Although its presentation is profound and dramatic, it does not appear to have any long-term sequelae. Patient 1 was a 70-year-old man with coronary bypass grafts who was referred for elective coronary angiography in July 2002 after myocardial infarction. Temazepam 10 mg was given as premedication. The procedure was carried out using low-osmolar, non-ionic contrast (Ultravist 370) and was uneventful. However, at the end of catheterization the patient appeared amnesic and perplexed. He was unable to recall events around the time of his hospital admission. There were no other neurological deficits. The patient recovered his memory completely over the next 24 h. Computed tomography (CT) scanning of the brain on the same day did not reveal any acute abnormality. Patient 2 was a 50-year-old man with a 12-month history of stable angina who was referred for elective angioplasty. Midazolam 2 mg was given as premedication for the procedure. Low-osmolar, non-ionic contrast (Ultravist 370) 310 mL was used for the complex coronary intervention. The procedure was uneventful. At the end of catheterization the patient was amnesic and could not recollect or register information. Again, there were no other neurological symptoms or signs. He recovered completely within 2 h with no residual neurological abnormality. This phenomenon after coronary angiography has rarely been reported in the literature, although its occurrence after cerebral angiography has been well described. 1–5 TGA was defined over 30 years ago, but its aetiology remains unknown. Proposed mechanisms include transient thrombo-embolic ischaemic attacks, epilepsy and migraine. 6 Diffusion-weighted magnetic resonance imaging provides conflicting evidence regarding a possible vascular ischaemic cause in mesiotemporal structures including the hippocampal region. Although some patients with epilepsy have episodes resembling TGA, there is little evidence that epilepsy causes TGA. The spreading depression of cerebral activity that is observed in migraine has been proposed as the mechanism causing hippocampal dysfunction. This hypothesis is based mainly on a finding of more migraine sufferers in patients with TGA. Classic TGA is often associated with distinct trigger events. Common events include physical exertion, severe emotional stress, painful experiences, immersion in cold water and sexual intercourse. It has been hypothesized that superior vena caval and cerebral venous congestion leading to hippocampal venous ischaemia can result from the valsalva manoeuvre and the sympathetic stimulation that accompany many of the common triggers. 6 Whether specific events relating to cerebral and coronary angiography, such as catheter-related cerebral atheroemboli or acute toxicity of contrast agents, play any role in angiography-related TGA is unclear. The question also remains as to whether these vastly different trigger events are causing the same syndrome. Furthermore, midazolam can cause amnesia and may affect memory differentially from its sedative effects. 7 However, it is unlikely to be the only explanation for the presentation of patient 2 because, in general, midazolam causes anterograde amnesia and not retrograde amnesia. 8

Serum lipid levels and the prevalence of dyslipidaemia among rural and urban Thai adults--are the NCEP III guidelines appropriate?

Abstract: The authors' objective was to describe the distribution of serum lipids and the prevalence of dyslipidaemia using US lipid-lowering guidelines in an adult Thai population. Fasting serum lipids were measured in a population-based survey that included 5305 rural and urban Thai adults aged 335 years. The US National Cholesterol Education Program (NCEP) guidelines were used to determine the eligibility of each individual for lipid-lowering therapy. Compared with urban residents, rural residents had lower mean levels of total cholesterol (men. 4.80 vs 5.54 mmol/L, women: 5.18 vs 5.71 mmol/L, both p < 0.001) and high density lipoprotein cholesterol (men: 1.06 vs 1.19 mmol/L, women: 1.13 vs 1.34 mmol/L, both p < 0.001). Mean triglyceride levels were higher in rural compared to urban populations, for both men (2.15 vs 1.88 mmol/L, p = 0.001) and women (1. 73 vs 1.51 mmol/L, p = 0.01). Direct application of the NCEP guidelines identified up to 37% of the adult population (or 10 million adult Thais) as eligible for lipid-lowering drug therapy, which is an unfeasibly high proportion of the population. Urgent strategies are required to prevent increasing levels of dyslipidaemia in Thailand, as well as to develop and promulgate treatment guidelines that incorporate locally-relevant risk prediction functions.

The role of the 12-lead ECG as a screening test for cardiac source of embolus.

Abstract: Background Investigation for cardiac source of embolus (CSE) is one of the commonest referrals for transthoracic echocardiography (TTE) of hospital inpatients, but has a relatively low-diagnostic yield. We sort to investigate whether 12-lead ECG might be useful in screening patients to obviate the need for TTE, in a subset of patients referred for echocardiographic investigation of cardiac source of embolus. Methods We collected ECG and echo data for 400 consecutively referred inpatients for TTE investigation of possible cardiac source of embolus. We analysed this data for evidence of cardiac source of embolism on TTE in patients with a normal or abnormal ECG. Results 41/400 (10%) subjects had possible CSE identified on TTE. Diagnostic yield for CSE was higher for those with abnormal compared with normal ECG (17% versus 6%, p Of those 168 (42%) with an abnormal ECG, TTE was normal in 73 and abnormal in 95, of whom 28 patients had an echo that identified a possible cardio-embolic source. ECG, therefore, had a sensitivity of 68%, specificity of 61%, positive predictive value of 0.17 and negative predictive value of 0.94 for detecting possible cardiac sources of embolus. Conclusions Although TTE is a relatively low-yield investigation for the detection of cardiac source of embolus, 12-lead ECG is not sufficiently sensitive to identify the ∼10% of patients in whom echo will demonstrate a diagnostic abnormality.