Ischemic Heart Disease Death Research Articles

Evaluating the quality of evidence for diagnosing ischemic heart disease from verbal autopsy in Indonesia.

BACKGROUNDMortality and cause of death data are fundamental to health policy development. Civil Registration and Vital Statistics systems are the ideal data source, but the system is still under development in Indonesia. A national Sample Registration System (SRS) has provided nationally representative mortality data from 128 sub-districts since 2014. Verbal autopsy (VA) is used in the SRS to obtain causes of death. The quality of VA data must be evaluated as part of the SRS data quality assessment.AIMTo assess the strength of evidence used in the assignment of Ischaemic Heart Disease (IHD) as causes of death from VA.METHODSThe sample frame for this study is the 4,070 deaths that had IHD assigned as the underlying cause in the SRS 2016 database. From these, 400 cases were randomly selected. A data extraction form and data entry template were designed to collect relevant data about IHD from VA questionnaires. A standardised categorisation was designed to assess the strength of evidence used to infer IHD as a cause of death. A pilot test of 50 cases was carried out. IBM SPSS software was used in this study.RESULTSStrong evidence of IHD as a cause of death was assigned based on surgery for coronary heart disease, chest pain and two out of: sudden death, history of heart disease, medical diagnosis of heart disease, or terminal shortness of breath. More than half (53%) of the questionnaires contained strong evidence. For deaths outside health facilities, VA questionnaires for male deaths contained acceptable evidence in significantly higher proportions as compared to those for female deaths. (P < 0.001). Nearly half of all IHD deaths were concentrated in the 50-69 year age group (48.40%), and a further 36.10% were aged 70 years or more. Nearly two-thirds of the deceased were male (58.40%). Smoking behaviour was found in 44.11% of IHD deaths, but this figure was 73.82% among males.CONCLUSIONMore than half of the VA questionnaires from the study sample were found to contain strong evidence to infer IHD as the cause of death. Results from medical records such as electrocardiograms, coronary angiographies, and load tests could have improved the strength of evidence and contributed to IHD cause of death diagnosis.

Long-term mortality rate for cardiovascular disease in 656 chronic myeloid leukaemia patients treated with second- and third-generation tyrosine kinase inhibitors

BackgroundLimited information is available regarding the rate of long-term cardiovascular (CV) mortality in chronic myeloid leukaemia (CML) patients treated with second- and third-generation tyrosine kinase inhibitors (2ndG/3rdG TKIs) in the real-life practice. MethodsWe identified 656 consecutive CML patients treated with nilotinib, dasatinib, bosutinib and ponatinib. ResultsThe 15-year CV-mortality free survival was 93 ± 2.8%. Age ≥65 years (p = 0.005) and a positive history of CV disease (p = 0.04) were significantly associated with a lower CV-mortality free survival. CV disease accounted for 16.5% and 5% of potential years of life lost (PYLL) in male and female patients, respectively. The standard mortality ratio (SMR) following ischemic heart disease (IHD) was 3.9 in males and 3.8 in female patients, meaning an excess of IHD deaths observed, in comparison with the population of control. Conclusion. Prevention strategies based on CV risk factors, in particular in those patients with a previous history of CV disease, should be considered.

High spatial resolution health risk assessment of road traffic noise on ischemic heart disease deaths for Melbourne, Australia in 2011

TPS 781: Health effects of noise, Exhibition Hall, Ground floor, August 27, 2019, 3:00 PM - 4:30 PM Introduction: Road traffic noise pollution increases risk of mortality from ischemic heart disease (IHD). Noise pollution is highly localized, so high resolution mapping of the exposure surface is a key concern. For health impact assessments optimally the data on exposure and health outcomes would both be available at small-area level. However, in Australia IHD deaths data are only easily accessed at low resolution, aggregated to local government areas (LGA, mean ~130,000 people). Our method utilizes low-resolution health data with high spatial resolution noise mapping for producing health risk maps at the mesh-block level (MB, ~75 people). Methods: We used a noise contour map for Melbourne, Australia from 2011 based on a spatial predictive model to estimate population exposures at the MB level. We used the non-linear exposure–response function for traffic noise and IHD as recommended by the World Health Organization to calculate attributable fractions of deaths for MBs. LGA-level IHD rates were then downscaled to MBs using publicly available data to estimate attributable numbers. Results: Average noise exposures for MBs was 35 dB and peaked at 72 dB. Approximately 5% of the population was exposed to traffic noise above the threshold of 55 dB. Attributable rates of IHD deaths due to noise were generally very low but in some MBs was as high as 5-10 per 100,000 and in extreme cases can represent more than 8% of the total expected burden of IHD death. Conclusion: Road traffic noise is a public health concern because it increases risk for IHD death. We present a method that does not require high resolution health data and can be used with high resolution exposure data to provide estimates of health risk. This method could be applied in a wide range of other environmental health settings.

Smoking-induced risk of future cardiovascular disease is partly mediated by cadmium in tobacco

TPS 771: Diet and lifestyle, Exhibition Hall, Ground floor, August 26, 2019, 3:00 PM - 4:30 PM Background: Smoking is a strong risk factor for cardiovascular disease (CVD) and causes exposure to cadmium, which is a pro-atherosclerotic metal. Cadmium exposure has also been shown to increase the risk of CVD, even after adjustment for smoking. Our hypothesis was that part of the risk of CVD in smokers may be mediated by cadmium exposure from tobacco smoke. We examined this hypothesis in a mediation analysis, trying to assess how much of the smoking-induced CVD risk could be explained via cadmium. Methods: We used prospective data on CVD (incidence and mortality) in a Swedish population-based cohort of 4304 middle-aged men and women (the Malmö Diet and Cancer Study). Blood cadmium was analyzed in base-line samples from 1991 - 1994, and clinical events were followed up for 16–19 years based on registry data. Mediation analysis was conducted to evaluate the indirect effect (via cadmium) of smoking on CVD. Survival was analyzed by the accelerated failure time (AFT) model and the Aalen additive hazard model. Results: The mean blood cadmium level in the study population was 0.43 μg/L (median 0.24 μg/L) and increased with recent and current smoking. As expected, shorter survival time (AFT model) and higher incidence rate (Aalen model) were found in current smokers for all CVD outcomes and this effect seemed to be partly mediated by cadmium. For the sum of acute myocardial infarction, bypass grafts and percutaneous coronary intervention, and death in ischemic heart disease, about half of the increased risk of such events in current smokers was mediated via cadmium, with similar results for the AFT and Aalen models. Conclusion Cadmium plays an important role in smoking-induced CVDs.

Do age, period or cohort effects explain circulatory disease mortality trends, Scotland 1974–2015?

ObjectiveWe aimed to explore whether age, period or cohort effects explain the trends and inequalities in ischaemic heart disease (IHD) and cerebrovascular disease (CeVD) mortality in Scotland.MethodsWe analysed IHD and...

A statistical downscaling approach for generating high spatial resolution health risk maps: a case study of road noise and ischemic heart disease mortality in Melbourne, Australia

IntroductionRoad traffic noise increases the risk of mortality from ischemic heart disease (IHD). Because noise is highly localized, high resolution maps of exposures and health outcomes are key to urban planning interventions that are informed by health risks. In Australia, publicly accessible IHD deaths data are only available at the coarse spatial aggregation level of local government area (LGA), in which about 130,000 people reside. Herein, we addressed this limitation of health data using statistical downscaling and generated environmental health risk maps for noise at the meshblock level (MB; ~ 90 people).MethodsWe estimated noise exposures at the MB level using a model of road traffic noise in Melbourne, Australia, from 2011. As recommended by the World Health Organization, a non-linear exposure–response function for traffic noise and IHD was used to calculate odds ratios for noise related IHD in all MBs. Noise attributable risks of IHD death were then estimated by statistically downscaling LGA-level IHD rates to the MB level.ResultsNoise levels of 80 dB were recorded in some MBs. From the given noise maps, approximately 5% of the population was exposed to traffic noise above the risk threshold of 55 dB. Maps of excess risk at the MB level identified areas in which noise levels and exposed populations are large. Attributable rates of IHD deaths due to noise were generally very low, but some were as high as 5–10 per 100,000, and in extremely noisy and populated MBs represented more than 8% excess risk of IHD death. We presented results as interactive maps of excess risk due to noise at the small neighbourhood scale.ConclusionOur method accommodates low-resolution health data and could be used to inform urban planning and public health decision making for various environmental health concerns. Estimated noise related IHD deaths were relatively few in Melbourne in 2011, likely because road traffic is one of many noise sources and the current noise model underestimates exposures. Nonetheless, this novel computational framework could be used globally to generate maps of noise related health risks using scant health outcomes data.

Differences between Arkansas and the United States in Prevalence of Risk Factors Explain Variations in Ischemic Heart Disease Mortality Rates among Pre-Medicare (45-64) and Medicare (65-84) Age Groups

Arkansas (AR) consistently has higher ischemic heart disease (IHD) death rates than the US, which is believed to be due to a higher prevalence in AR of major, modifiable risk factors. We examined the difference in IHD death rates between AR and the US as consequences of differences in the prevalence of nine risk factors between pre-Medicare age group (45-64) and Medicare age group (65-84). We modeled IHD deaths attributable to differential prevalence between AR and the US using mortality data and prevalence data from AR and US for years 2000-2010, and relative risk measures obtained from the INTERHEART and Atherosclerosis Risk in Communities studies. From 2000-2010, our study showed that if we were to reduce the prevalence of significant risk factors to US levels, we would reduce AR IHD deaths by 26.6% in the pre-Medicare age group and 15.9% in the Medicare age group. Most of the increased mortality was explained by higher prevalence of smoking and hypertension in AR. Other socioeconomic factors that contributed to an increased risk of poor health outcomes were education, income, and the lack of health insurance; with AR having worse outcomes than the US for the pre-Medicare age group. The importance of risk factors depended on race, sex, and age. The excess mortality in AR relative to the US for the two age groups can largely be explained by prevalence differences in smoking, hypertension, cholesterol, education and income.

SUN-046 CARDIAC MORTALITY IN PEOPLE WITH END STAGE KIDNEY DISEASE IN AUSTRALIA AND NEW ZEALAND; A COHORT STUDY FROM 1980 TO 2013

The presence of cardiac disease is an important predictor of mortality in people with end-stage kidney disease (ESKD). Secondary prevention and treatment of cardiac events may be less effective in people with ESKD. We aimed to review the rates and standardised mortality ratios from cardiovascular disease for people with ESKD compared to the Australian and New Zealand general population. Cohort study of incident people with ESKD in Australia and New Zealand, 1980-2013. Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) was linked with Australian and New Zealand death registers to obtain date and cause of death. We estimated mortality rates for cardiovascular disease using ICD codes (Table 1) and standardised mortality ratios (SMRs with 95% confidence intervals [CI]) using indirect standardisation, by age, sex and calendar year to the general population. There were 60,823 participants contributing 381,874 person-years of follow-up. Overall, there were 6847 cardiac deaths, of which 5947 (86.9%) were from ischaemic heart disease. Cardiac mortality rates were higher in men (2002.5/100,000 person-years, 95%CI: 1944.5-2062.2) than women (1502.5/100,000person-years, 95%CI: 1443.6-1563.8), where rates in both sexes increased with age. The relative rate was higher in women (women: SMR 8.3, 95%CI: 8.0-8.6; men: SMR 5.6, 95%CI: 5.5-5.8). The burden of excess mortality was greatest for younger women with ESKD (aged 30-49 years: women SMR 59.7, 95%CI: 51.8-69.0; men SMR 17.7, 95%CI: 15.9-19.7) Subgroup analysis showed this was largely driven by ischaemic heart disease deaths (Figure 3).Table 1ICD 10 CodesICD 10 CodeGrouped outcomesI20-I25Ischaemic heart diseasesI34-I37Valvular diseasesI42-I43CardiomyopathyI44-I49ArrhythmiasI50Heart failure Open table in a new tab View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) The cardiac mortality rates in the Australian and New Zealand ESKD population are substantially higher than the general population. Young women with ESKD have an excessive relative risk of dying from cardiac disease, in particular IHD, compared to young females in the general population.

Smoking-induced risk of future cardiovascular disease is partly mediated by cadmium in tobacco: Malm\xf6 Diet and Cancer Cohort Study

BackgroundSmoking is a strong risk factor for cardiovascular disease (CVD) and causes exposure to cadmium, which is a pro-atherosclerotic metal. Cadmium exposure has also been shown to increase the risk of CVD, even after adjustment for smoking. Our hypothesis was that part of the risk of CVD in smokers may be mediated by cadmium exposure from tobacco smoke. We examined this hypothesis in a mediation analysis, trying to assess how much of the smoking-induced CVD risk could be explained via cadmium.MethodsWe used prospective data on CVD (incidence and mortality) in a Swedish population-based cohort of 4304 middle-aged men and women (the Malmö Diet and Cancer Study). Blood cadmium was analyzed in base-line samples from 1991, and clinical events were followed up for 16–19 years based on registry data. Mediation analysis was conducted to evaluate the indirect effect (via cadmium) of smoking on CVD. Survival was analyzed by the accelerated failure time (AFT) model and the Aalen additive hazard model.ResultsThe mean blood cadmium level in the study population was 0.43 μg/L (median 0.24 μg/L) and increased with recent and current smoking. As expected, shorter survival time (AFT model) and higher incidence rate (Aalen model) were found in current smokers for all CVD outcomes and this effect seemed to be partly mediated by cadmium. For the sum of acute myocardial infarction, bypass grafts and percutaneous coronary intervention, and death in ischemic heart disease, about half of the increased risk of such events in current smokers was mediated via cadmium, with similar results for the AFT and Aalen models.ConclusionsCadmium plays an important role in smoking-induced CVDs. This provides evidence for mechanisms and is of importance for both individuals and policy makers.

Abstract P224: Chili Pepper Intake and Risk of Total and Cardiovascular Mortality in Italian Adults: Prospective Findings From the Moli-Sani Study

Introduction: Chili pepper, along with other spices, is an integral part of a traditional Mediterranean diet (MD). Yet there is paucity of epidemiological data on the association between chili pepper intake and mortality risk, with lack of studies from Mediterranean populations. Hypothesis: We assessed the hypothesis of an association between chili pepper consumption and total and cardiovascular (CVD) risk of death in a large sample of the Italian general population, and tested different biological mediators of the association. Methods: Longitudinal analysis on 22,811 men and women aged≥35 years enrolled in the Moli-sani Study cohort, Italy (2005-2010). Chili pepper intake was estimated by the EPIC food frequency questionnaire and categorized as none/rare consumption, up to 2 times/week, 2-4 and &gt; 4 times/week. Multivariable hazard ratios (HR) with 95% confidence intervals (95%CI) were calculated by multivariable Cox regression and competing risk models. Results: Over a median follow up of 8.2 years, a total of 1,236 deaths were ascertained, of which 444 from CVD. Multivariable risk estimates for all-cause and CVD mortality among participants in the regular (&gt;4 times/week) relative to the none-rare intake were, respectively, 0.77 (0.66-0.90) and 0.66 (0.50-0.86). Regular intake also lowered ischemic heart disease (0.55;0.35-0.87) and cerebrovascular death risks (0.39;0.20-0.76). Traditional CVD risk factors (e.g. blood cholesterol, triglycerides) only marginally account for such associations (Table). Conclusions: In a large Mediterranean population, regular consumption of chili pepper is associated with lower risk of total and CVD death independent of adherence to MD. Known biomarkers only marginally accounted for the association of chili pepper intake with total mortality.

Diesel Exhaust, Respirable Dust, and Ischemic Heart Disease: An Application of the Parametric g-formula.

Although general population studies of air pollution suggest that particulate matter-diesel exhaust emissions in particular-is a potential risk factor for cardiovascular disease, direct evidence from occupational cohorts using quantitative metrics of exposure is limited. In this study, we assess counterfactual risk of ischemic heart disease (IHD) mortality under hypothetical scenarios limiting exposure levels of diesel exhaust and of respirable mine/ore dust in the Diesel Exhaust in Miners Study cohort. We analyzed data on 10,779 male miners from 8 nonmetal, noncoal mines-hired after diesel equipment was introduced in the respective facilities-and followed from 1948 to 1997, with 297 observed IHD deaths in this sample. We applied the parametric g-formula to assess risk under hypothetical scenarios with various limits for respirable elemental carbon (a surrogate for diesel exhaust), and respirable dust, separately and jointly. The risk ratio comparing the observed risk to cumulative IHD mortality risk at age 80 under a hypothetical scenario where exposures to elemental carbon and respirable dust are eliminated was 0.79 (95% confidence interval [CI]: 0.64, 0.97). The corresponding risk difference was -3.0% (95% CI: -5.7, -0.3). Our findings, based on data from a cohort of nonmetal miners, are consistent with the hypothesis that interventions to eliminate exposures to diesel exhaust and respirable dust would reduce IHD mortality risk.

The Overlap between Cancer and Cardiovascular Diseases Mortality

Introduction: Cardiovascular diseases (CVD) and cancer, the two most common causes of death globally, have several shared risk factors. However, evidence on the extent of their overlap as causes of death is limited. Objective: To examine the overlap between CVD and cancer mortality. Methods: We used Baker Biobank data that were linked to Australian National death index. Of the 6530 participants in the Biobank, there were 1584 deaths. Underlying, associated and multiple causes of death were used in determining the overlap. Hazards of overlap and shared prognostic factors were also considered in the analysis. Proportions, logistic regression and Cox regression models were used in the analysis. Results: Overall, 141 (8.9%) of the deaths had both CVD and Cancer mentioned as causes of death. About 21% of ischaemic heart disease deaths, 13% of heart failure deaths and 13% of stroke deaths had cancer as a co-occurring cause of death. Deaths with cancer as underlying cause of death were 2.8 times more likely to have CVD as an associated cause of death. Among deaths where CVD was mentioned as a cause of death, there was a 93% higher probability of cancer being reported as a co-occurring cause of death. Patients with history of CVD were 5 times more likely to have cancer as cause of death; and 6 times more likely to have both CVD and cancer as causes of death. Conclusion: There is a significant overlap between CVD and cancer mortality. Integrated screening and management of CVD and cancer is recommended.

Prognostic value of left atrial strain in predicting cardiovascular morbidity and mortality in the general population.

Left atrial (LA) enlargement predicts cardiovascular risk. The prognostic value of left atrial peak reservoir strain (LA RS) by two-dimensional speckle tracking in the general population is currently unknown. This study sought to determine the prognostic value of LA RS in the general population. A total of 385 participants without atrial fibrillation, heart failure (HF), and ischaemic heart disease (IHD) had an echocardiogram including left ventricular and LA speckle-tracking analysis performed. LA RS was averaged from the three apical views. The endpoint was a composite of incident IHD, HF, or cardiovascular death. Median follow-up was 12.6 years (interquartile-range 11.5-12.8 years). Follow-up was 100%. Fifty-one participants (13.3%) reached the composite outcome. LA RS was a univariable predictor of outcome [hazard ratio (HR) 1.25, 95% confidence interval (95% CI) 1.09-1.43; P = 0.002]. However, LA RS did not remain an independent predictor of outcome after adjustment for clinical parameters. The prognostic value was modified by sex (P = 0.011). LA RS predicted the composite outcome in women but not in men when adjusting for clinical parameters (women: HR 1.46, 95% CI 1.05-2.02; P = 0.025) (men: HR 0.96, 95% CI 0.81-1.14; P = 0.65). Further adjustment for echocardiographic parameters did not significantly alter the results. LA RS added incremental prognostic information in addition to SCORE and the American Heart Association/American College of Cardiology Pooled Cohort Equation in women only. LA RS is a univariable predictor of cardiovascular morbidity and mortality in the general population. However, the prognostic value of LA RS is modified by sex. LA RS is an independent predictor of outcome in women but not in men.

Does Telemedicine Save Lives? Evidence on the Effect of Telemedicine Parity Laws on Mortality Rates

Between 1995 and 2018, just over half of the U.S. states enacted laws requiring private insurance plans cover medical care provided remotely using various technologies. These telemedicine parity laws likely increase health care access, particularly in areas with few providers, by granting patients access to specialists or primary care providers located elsewhere. The effect of these laws on health outcomes is ambiguous. We estimate the effect of telemedicine parity laws on mortality rates of all causes and for causes of death due to conditions more frequently treated with telemedicine. We find declines in mortality rates post-parity laws, driven by decreases in ischemic heart disease deaths. Our results suggest that relaxing current telemedicine regulations in programs such as Medicare might improve patient outcomes.

A Decade of NT-proBNP in Acute Kawasaki Disease, from Physiological Response to Clinical Relevance.

Kawasaki disease (KD) is an inflammatory febrile illness of early childhood and the primary cause of acquired heart disease during childhood. Coronary artery aneurysms (CAA) are a serious complication of KD, leading to ischemic heart disease, myocardial infarction, and sudden cardiac death. Timely diagnosis in the first ten days of fever is crucial to reduce the risk of coronary artery complications. Nitrogen-terminal B-type natriuretic peptide (NT-proBNP), originally used for the management of adults with heart disease, was shown to be useful in the diagnosis and management of patients with KD. NT-proBNP is released by cardiomyocytes in response to mechanical factors such as the dilation of cardiac chambers, and to pro-inflammatory cytokines. The utility of NT-proBNP as a biological marker in KD is based on the universal myocardial inflammatory component early in the course of the disease. Patients with KD have higher NT-proBNP at the time of diagnosis than febrile controls, with a pooled sensitivity of 89% (95% confidence interval 78–95), and a specificity of 72% (95% confidence interval 58–82). The positive likelihood ratio is 3.2:1 (95% confidence interval 2.1–4.8). Moreover, patients with resistance to intravenous immunoglobulin treatment and CAA were found to have higher levels of NT-proBNP, suggesting a prognostic role. Nevertheless, the non-specificity of NT-proBNP to KD limits its use as a stand-alone test. In this light, a tentative associative retrospective diagnostic algorithm was highly reliable for including all cases at risk of CAA, which warrants further prospective studies for a better diagnostic index of suspicion and risk stratification of patients.

Association between central obesity and risk for heart disease in adults in China: a prospective study

Objective: To understand the association between central obesity, assessed by waist circumference, and the risks for ischemic heart disease (IHD), major coronary event (MCE), and IHD death. Methods: After excluding participants with heart disease, stroke, cancer, COPD, and diabetes at baseline survey, we included a total of 428 595 participants from the China Kadoorie Biobank for the analysis. The baseline survey was conducted from June 2004 to July 2008. We used Cox proportional hazards model to estimate the hazard ratio (HR) and 95%CI. Results: During an average 9.1 years of follow-up (3 803 637 person-years), we documented 26 900 incident cases of IHD, 4 320 cases of MCE, and 2 787 of deaths from IHD. After adjustment for possible confounders and BMI, central obesity was found to be associated with increased risks for IHD, MCE, and IHD death. The adjusted HRs (for the participants who had waist circumference of 85.0-89.9 cm in men and 80.0-84.9 cm in women were 1.13 (95%CI: 1.09-1.17) for IHD, 1.15 (95%CI: 1.05-1.26) for MCE and 1.11 (95%CI: 0.98-1.24) for IHD death. The respective HRs for those central obese participants (men ≥90.0 cm, women ≥85.0 cm) were 1.29 (95%CI: 1.24-1.34), 1.30 (95%CI: 1.17-1.44) and 1.32 (95%CI: 1.16-1.51). Further stratification analysis according to BMI showed that the risks for incident IHD, MCE, and IHD death increased along with the increase of waist circumference even in the participants with normal weight. Conclusion: This large-scale prospective study revealed that central obesity was an independent risk factor for IHD in adults in China, and the risk of IHD would increase with the increase of waist circumference.

Preventable deaths within Brazil's Public Health System in a population from 5 to 69 years old, 2000 - 2013.

To analyze the mortality trend in the Brazilian population aged between 5 and 69 years old, using the "Brazilian List of Causes of Preventable Deaths". This is an ecological study that uses a time-series analysis of the standardized mortality rate for preventable and unpreventable causes in the period from 2000 to 2013, with corrections for ill-defined causes and the under-reporting of informed deaths. There was a decline in the mortality rate in the Brazilian population aged 5 to 69 due to preventable causes (1.6% per year) and unpreventable causes (1.4% per year), in addition to a decrease among all of the groups of causes of preventable deaths in the period from 2000 - 2013. The study draws attention to the increase in deaths from specific causes such as pneumonia (1.9% per year) and transportation accidents (0.6% per year), as well the stability in the number of deaths from aggression and intentional self-harm. Deaths from noncommunicable diseases fell by 2.2% per year and were highest in the age group of 60 - 69 years old in 2013 (209.9/100,000 inhabitants for ischemic heart disease deaths, 157.2/100,000 inhabitants for cerebrovascular diseases and 116.8/100,000 inhabitants for diabetes). The rates of preventable deaths are still high, especially for noncommunicable diseases and external causes. These causes of death are sensitive to health promotion interventions and, therefore, this study reinforces the need to remain focused on these causes of illness and death, as well as their risk factors.

Association between Extremely Cold Weather and Ischemic Heart Disease-Related Death during 2011-2017, Jinan City

Objective: The objective of the study is to evaluate the acute effects of extreme cold weather and cold waves on the risk of death from ischemic heart disease (IHD) in Jinan city. Methods: Daily meteorological data, air pollution data, and IHD-related death data in Jinan from January 1, 2011, to December 31, 2017, were collected. The extreme cold weather was defined as temperatures below the 10th percentile (−1.6 C), 5th percentile (−3.3 C), and 1st percentile (−6.4 C) of the daily average temperature during the study period, expressed as P10, P5, and P1 respectively. Cold strokes were defined as P10, P5, or P1 temperatures lasting for 3 days or more, and were expressed as Cold stroke I, Cold stroke II, and Cold stroke III, respectively. A time-stratified case-crossover study was used to assess the acute effects of extreme cold weather and cold strokes on IHD-related deaths. Results: During the 1486 days of the 2011–2017 cold months, 50,845 IHD deaths were detected with an average of 34 daily deaths. The relatively cold years were observed in 2011, 2012, 2013 and 2016 during the study, and the coldest was for 2012. The maximum effects of P10, P5, and P1 on IHD deaths occurred on lag6, lag6, and lag2, respectively, and the results were 1.08 (95% confidence interval [CI]: 1.04, 1.12), 1.10 (95% CI: 1.04, 1.15), and 1.20(95% CI:1.09, 1.32), respectively. The maximum effect of Cold stroke I and Cold stroke II on IHD mortality risk was 1.09 (95% CI: 1.04, 1.14) and 1.11 (95% CI: 1.04, 1.19), respectively, at lag6 and lag2. Conclusions: Extremely cold weather and cold strokes in the cold months of 2011–2017 in Jinan City significantly increased the risk of acute death from IHD. It was also found that the occurrence of cold weather and cold strokes after warm years can further increase the risk of acute death from IHD.

Pregnancy-associated plasma protein A and mortality in haemodialysis

Elevated pregnancy-associated plasma protein A (PAPP-A) levels are associated with increased risk of death in ischaemic heart disease as well as in haemodialysis patients. Previous research indicates that the prognostic value of PAPP-A may be stronger in patients with concomitant diabetes mellitus or signs of inflammation. We studied the association between PAPP-A and outcomes in prevalent haemodialysis patients and hypothesized that diabetes mellitus and inflammation status act as effect modifiers. Circulating PAPP-A levels were quantified using ELISA. Cox proportional hazards and quantile regression models were used for associations between PAPP-A and mortality. PAPP-A levels were log-transformed for Normality. During 60-month follow-up, 37 (40%) of the 92 participants died. Higher PAPP-A was associated with increased risk of mortality in unadjusted analysis (HR per SD=1.4, 95% CI=1-1.9, P=.03) and when adjusted for confounders and cardiovascular risk factors (HR=1.8, 95% CI=1.18-2.73, P=.006). An interaction between PAPP-A levels and diabetes mellitus on mortality was found (HR for the multiplicative interaction term=2.74 95% CI=1.02-7.37, P=.05). In a quantile regression adjusted for age and sex, one SD increase in PAPP-A was associated with 22months shorter estimated time until 25% of the patients died (95% CI -35 to -9.1months). Increased PAPP-A levels are associated with higher all-cause mortality in prevalent haemodialysis patients with concomitant diabetes mellitus.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

SummaryBackgroundSeveral studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.MethodsIn our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.ResultsIndividual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97–2·24) and tripled risk among women (3·00, 2·71–3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35–59 years: 2·60, 2·30–2·94) than in older individuals (aged 70–89 years: 2·01, 1·85–2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35–59 years had the highest death RR across all age and sex groups (5·55, 4·15–7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35–59 years, the excess absolute risk was 0·05% (95% CI 0·03–0·07) per year in women compared with 0·08% (0·05–0·10) per year in men; the corresponding excess at ages 70–89 years was 1·08% (0·84–1·32) per year in women and 0·91% (0·77–1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.InterpretationIndependent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.FundingUK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).