South Asians and cardiovascular risk: what clinicians should know.
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Adult↗
Biomedical subjects
Milan Gupta
Publications and source records attributed to Milan Gupta.
Is South Asian ethnicity an independent cardiovascular risk factor?
People of South Asian origin constitute a large, visible minority in Canada and are known to be at heightened risk for premature coronary artery disease. Conventional risk factors clearly confer risk in South Asians but do not adequately explain their excess risk compared with other populations. Rates of smoking, hypertension and levels of low density lipoprotein-cholesterol tend to be similar or lower in South Asians, although diabetes is more prevalent. Recent studies have suggested that the metabolic syndrome and abdominal obesity may play a causative role in both the prevalence of diabetes and the premature atherosclerosis noted in South Asians. It is possible that genetically susceptible individuals develop abdominal obesity and insulin resistance when exposed to a toxic environment of reduced energy expenditure and increased caloric consumption. This pattern is increasingly noted in parallel with urbanization, suggesting that the increased cardiovascular risk in South Asians may be preventable through lifestyle interventions and the judicious use of medicines to attain optimal levels of blood pressure, lipids and glucose.
Asia↗
Non ST segment elevation acute coronary syndromes: A simplified risk-orientated algorithm.
Non-ST segment elevation acute coronary syndromes (NSTE ACS) include a clinical spectrum that ranges from unstable angina to NSTE myocardial infarction. Management goals aim to prevent recurrent ACS and improve long-term outcomes by choosing a treatment strategy according to an estimate of the risk of an adverse outcome. Recent registry data suggest that patients with NSTE ACS frequently do not receive recommended treatment, and that risk stratification is not used to determine either the choice of treatment or the speed of access to coronary angiography. The present article evaluates the evidence for recommended treatment using information from recent trials and guidelines published by the major cardiac organizations in Europe and North America. Using this information, a multidisciplinary group developed a simplified algorithm that uses risk stratification to select an optimal early management strategy. Long-term outcomes are improved by a multi-faceted vascular protection strategy that is initiated at the time of hospitalization for NSTE ACS.
Acute Disease↗
Should patients with stable coronary artery disease be treated with ACE inhibitor therapy?
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Angiotensin-Converting Enzyme Inhibitors↗
Clinical characteristics of South Asian patients hospitalized with heart failure.
Ethnic variations in prevalence, presentation characteristics, and mortality have been identified in Canadian patients with coronary artery disease. Similar data with respect to heart failure do not exist. A retrospective sequential chart review of South Asians and non-South Asian Whites in Canada hospitalized with a primary diagnosis of congestive heart failure between 1997 and 1999 showed South Asians were significantly younger, of lower body mass index, were more often diabetic, and were less often smokers. In-hospital mortality was not different between groups, although South Asians were more likely to experience ventricular arrhythmias. Despite presenting at a younger age, South Asians had more high-risk features at hospital discharge. Since South Asians are at high risk of developing premature coronary artery disease, a more aggressive approach to prevention strategies in this ethnic group may reduce the subsequent burden of heart failure.
Aged↗
International differences in in-hospital revascularization and outcomes following acute myocardial infarction: a multilevel analysis of patients in ASSENT-2.
BACKGROUND: Revascularization rates vary substantially between countries in patients with acute ST-elevation myocardial infarction (STEMI). The impact of early revascularization on clinical outcomes in such patients remains uncertain. The ASSENT-2 fibrinolytic trial provides the opportunity to compare revascularization rates following STEMI in patients across 29 countries, and to explore the relationship between revascularization and clinical outcome. METHODS: Countries participating in ASSENT-2 were grouped into tertiles according to their in-hospital revascularization rates (<15%, 15-39%, >39%). Baseline characteristics, medication and procedure use, and clinical outcomes of the 16949 patients enrolled were compared. Multiple Cox regressions were used to assess the relationship between the tertiles and 30-day mortality, the primary endpoint of the ASSENT-2 trial. Multilevel logistic regression models were developed to validate and further extend the findings from the single-level analyses. RESULTS: Patients in highest tertile countries were younger, heavier, and more often diabetic or hypertensive. They were more likely to have had a previous myocardial infarction or revascularization procedure. Time to treatment and hospital length of stay were shorter in the highest tertile, and beta-blocker use was more frequent. Stroke rates were low and similar across tertiles, with no statistically significant difference in rates of intracranial haemorrhage. Recurrent ischaemia and reinfarction were less common in the highest tertile. Mortality rates at 30 days were lower for countries with the highest revascularization rates (5.1% vs 6.9% vs 6.5% for the lower two tertiles, P<0.001). At 1 year, mortality remained significantly lower in the highest tertile countries (8.4% vs 10.6% vs 9.9%, P=0.001). Following adjustment for baseline patient characteristics, Cox regression analysis confirmed an excess of 30-day and 1-year mortality in the lowest and intermediate tertiles compared to the highest tertile. The multilevel analyses validated these findings, and demonstrated that a country's life expectancy and the hospital volume were inversely related to both 30-day and 1-year mortality. CONCLUSIONS: The highest rate of in-hospital revascularization following fibrinolytic therapy for acute myocardial infarction in this international study was associated with a reduction in recurrent ischaemia, reinfarction, and improved survival at both 30 days and at 1 year. The optimal rates of revascularization in this setting remain to be determined.
Aged↗
Risk factors, hospital management and outcomes after acute myocardial infarction in South Asian Canadians and matched control subjects.
BACKGROUND: Coronary artery disease affects a significantly larger proportion of Canadians of South Asian origin than Canadians of other ethnic origins. We compared differences in presentation, risk factors and management of myocardial infarction (MI) between South Asian Canadians and matched control subjects. METHODS: We reviewed the charts of 553 South Asian patients and 553 non-South Asian matched control subjects presenting with acute MI (International Classification of Diseases code 410) to 2 hospitals in Canada from January 1994 to April 1999. We identified South Asian subjects by their surnames and first names, and by using self-reported ethnicity and country of birth when available. Patients of Southeast Asian and Middle Eastern origin were excluded. The remaining patients were classified as non-South Asian. Subjects were matched by age within 5 years, sex, discharge date within 6 months and hospital of admission. Presentation characteristics, risk factors and major complications were compared between the 2 groups. RESULTS: The median time from symptom onset to presentation with acute MI was significantly longer among the South Asian subjects than among the control subjects (3.92 v. 3.08 hours) (p = 0.04). The South Asians were more likely than the control subjects to have diabetes mellitus (43.4% v. 28.2%) (p < 0.001) despite having a significantly lower mean body mass index (25.7 v. 28.0) (p = 0.05) but were less likely to have hyperlipidemia (36.2% v. 42.7%, p = 0.05), to smoke (29.3% v. 67.8%) (p < 0.001) or to have pre-existing vascular disease (49.4% v. 55.0%, p = 0.04). Treatment of acute MI was similar between the South Asian and matched control groups. Also similar were the in-hospital outcomes, including mortality (9.6% and 7.8%, p = 0.27). INTERPRETATION: There are clear differences in the risk factor profile between Canadians of South Asian origin and those of non-South Asian origin who have acute MI. Despite the higher incidence of cardiovascular disease in the South Asian population, our results indicate that the in-hospital case-fatality rate for MI is the same for South Asian and non-South Asian Canadians.
Asia, Southeastern↗
Preventing thrombosis: update of first-line therapy in the management of non-ST segment elevation acute coronary syndromes.
Non-ST segment elevation acute coronary syndrome (NSTE ACS) has a high rate of recurrence. Both antithrombotic and antiplatelet agents in association with coronary revascularization play an important role in the prevention of an adverse outcome. Acetylsalicylic acid, heparin and low molecular weight heparin (especially enoxaparin), and the intravenous small-molecule glycoprotein IIb/IIIa inhibitors, are of proven value. Recently, clopidogrel has been shown to reduce recurrent ischemic events, both early and during the first year after the index ACS. Furthermore, two recent trials have shown that an early invasive strategy is preferable to a conservative approach in the higher risk patient. As yet, no study has shown either the efficacy or the safety of combining all these treatment modalities in the management of the NSTE ACS patient. The initial choice of antithrombotic and antiplatelet agents and a strategy for early revascularization is made after considering the risk of recurrent acute ischemic events. For patients destined to have an early invasive strategy, it is desirable to choose an anti-thrombotic/antiplatelet combination that will reduce events before revascularization, enhance the revascularization procedure and not be associated with excessive bleeding. A risk-determined algorithm is presented, which applies observations made at the time of presentation to decide the optimal management for the individual patient.
Acute Disease↗