Mr Tachibana and Dr Ikeda 21 (Japanese Edition)

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Regarding stroke, the association between TC and hazard ratio differed because of cerebral infarction and hemorrhagic stroke primarily intracerebral hemorrhage.

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For hemorrhagic strokes, in contrast with the increase in risk of occurrence at low TC levels 55 — 57 , an increased risk because of high TC levels was observed in ischemic stroke, as with in CAD 58 , But at the same time, there are reports stating that an association does not exist in regard to stroke.

As non-HDL-C includes all arteriosclerosis-causing lipoproteins, such as remnant lipoproteins, there are views that claim its relatively superior ability in predicting the CAD incidence in comparison with LDL-C 61 , Meanwhile, studies concerning the association between non-HDL-C and stroke have reported varying results. There are reports saying that the association is unclear 51 , 67 , and there are also those that revealed an increase in risk when non-HDL-C levels were low On the basis of the results above, we concluded that non-HDL-C is possibly a useful indicator for predicting the risk of CAD incidence and mortality.

On the contrary, the risk decreases when HDL-C levels are high 39 , 53 , 76 — Likewise, in the J-LIT study that involved a cohort of simvastatin users, the relative risk was 1. In addition, the relative risk was higher at 1. However, there have also been reports from large-scale cohort studies involving only the Japanese that low levels of HDL-C by itself does not constitute a risk for CAD Women generally have a higher HDL-C level than men 46 , 80 , However, there is still insufficient evidence on the association between the discrepancy in HDL-C levels because of gender differences and CAD in each gender Therefore, in these guidelines, we have set the reference value for women to be the same as men.

An increase in TG level, whether fasting or nonfasting, predicts the CAD and ischemic stroke incidence and mortality in the future. Although TG is traditionally tested with blood collected in a fasting state, some reports have stated that its ability to predict the risk for cardiovascular events is higher using blood collected in a nonfasting state Furthermore, there have been many reports on hypertriglyceridemia being a risk factor for ischemic stroke, though the association is weaker than that with CAD 46 , 65 , 87 , 93 — However, hypertriglyceridemia often comes with other important implications, such as an increase in the amount of remnant lipoproteins or small dense LDL and the co-existence of hypo-HDL cholesterolemia.

It could also be a finding of metabolic syndrome, and hence, other factors accompanying an elevated TG level should also be thoroughly considered. Among the different types of stroke, the association with cerebral infarction has been found to be almost similar to that with CAD.

However, for hemorrhagic stroke primarily intracerebral hemorrhage , the incidence and mortality rates are instead higher at low LDL-C and TC levels. At present, the absolute risk of CAD incidence and mortality rate in Japan is very much lower than that in the Western countries However, there have been reports and such revealing that the LDL-C and TC levels of the Japanese have been on the rise because of recent westernization of lifestyle habits. As a result of this change, the TC levels of the Japanese have already reached the levels in the US, or even higher These reports have also pointed out the increasing incidence rate of CAD in some regions in Japan 98 , 99 , and this is why the management of dyslipidemia is of importance.

In these guidelines, we have therefore established the diagnostic criteria for dyslipidemia with a focus on preventing the development of CAD.

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The diagnostic criteria are shown in Table 1. However, measurement using the direct method is also allowed.

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Even though problems with the accuracy of the direct method have been pointed out , there have recently been the discontinuation of sales and production, improvement and revision of standard pricing of reagents that were found to be mediocre over time. As a result of the improved performance of reagents, the validity of LDL-C measurement within daily clinical practice has been substantiated However, most of the studies providing evidence relating to the treatment of hyper-LDL cholesterolemia have used the Friedewald formula to determine LDL-C levels.

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It should be noted that the diagnostic criteria, treatment targets and such are based on the Friedewald formula. Other methods of assessment should be considered in such cases. Passive smoking is a risk factor for CAD and stroke. Smoking has been reported to be a risk factor for CAD and stroke in a number of sources, such as cohort studies conducted overseas and in Japan, as well as their meta-analyses.

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Compared to nonsmokers, smokers face a higher risk for CAD and stroke, and there is a dose-response relationship in this association In addition, there has been no data showing that low-tar, low-nicotine tobacco decreases the risk for these diseases. The risk increases even when the number of cigarettes smoked per day is less than five Reviews in Japan alone have shown that smoking has been consistently reported in many cohort studies — to be a risk factor.

Compared to lifetime nonsmokers, the relative risk for developing CAD and death from it was 2. Furthermore, the relative risk of getting stroke and stroke-related death was 1. Other than that, a metaanalysis of cohort studies in Japan have shown that for abdominal aortic aneurysm AAA , the relative risk is 3. The dose—response relationship has also been made apparent in the analysis. The dose—response relationship has similarly been demonstrated in these studies On the other hand, for passive smokers, it has been revealed in a meta-analysis that the relative risks for CAD and stroke are 1.

Smoking increases the risk for developing type 2 diabetes to 1. It also increases the risk for diabetes, dyslipidemia and metabolic syndrome, in turn contributing to an added risk for ASCVD. Recently, new forms of tobacco heat-not-burn tobacco products and electronic cigarettes, etc that differ from the conventional combustion cigarette have been in circulation. As these new forms of tobacco have only been in circulation for a short period of time, their effects on health, such as the risk for ASCVD and related death, cannot be determined at this point of time.

Nonetheless, although heat-not-burn tobacco products do not contain substances that are produced by combustion, users still inhale and exhale the aerosol generated by heating the tobacco leaves and additives, including nicotine Moreover, from the fact that various carcinogens have been reported to be found in the aerosol, regardless of whether electronic cigarettes contain nicotine , the use of any of them has a possibility of adversely affecting health. Blood pressures that exceed the optimal reading i.

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Hypertension at middle age also increases the risk for dementia when one reaches old age This association was stronger in the middle-aged adults than in the elderly They were all assessed to be caused by high BPs that exceed the optimum level. Among all deaths from these causes, subjects with grade-I hypertension made up the highest proportion A comparison between subjects with hypertension and those without hypertension in the lipid intervention study J-LIT showed that the relative risk for CAD in primary prevention subjects was 2.

The basis for diagnosing hypertension is usually the BP reading measured at the outpatient clinic. However, it has been reported that BP measurements at home and hour ambulatory BP monitoring ABPM can predict the incidence of cardiovascular events better than in-clinic BP measurements. In The Japanese Society of Hypertension's Guidelines for the Management of Hypertension JSH , it has been explicitly stated that if the diagnosis made with in-clinic BP readings differs from that with home BP readings, BP-lowering effects should be determined and diagnosis should preferably be made on the basis of the BP measured at home The Hisayama study reported that the incidence rate of CAD and cerebral infarction in diabetic patients were both high after adjusting multiple factors, such as gender and age.

In this study, the incidence rate of CAD was 5. Similarly, the incidence rate of cerebral infarction was 6. The CIRCS study also showed that the incidence rate of cerebral infarction for diabetic patients was higher at 1. Silent myocardial ischemia often coexists in diabetic patients, and this may result in delayed diagnosis Features of coronary lesions in diabetic patients include 1 multiple-vessel disease, 2 highly complicated and diffuse , and 3 multiple calcified lesions As for cerebral infarction, the JPHC study has shown that lacunar infarction, atherothrombotic infarction and thromboembolic infarction occur more often in diabetic patients than non-diabetic subjects Furthermore, prognosis of CAD in diabetic patients is worse than in non-diabetic subjects — , and also have a higher risk for recurrence of cerebral infarction , The two hours glucose level post glucose load was more strongly associated with the risk for CAD than the fasting level in subjects with IGT , These suggest that the significance of postprandial glucose level as a risk factor of atherosclerosis.

Women generally have a lower risk for CAD than men. But in diabetic patients, it has been reported that the increase in relative risk of CAD was higher in women than men, resulting in reduced gender differences , It has also reported that compared to male subjects with NGT male diabetic patients increased the risk of CAD by 17 times higher at ages 31—40 years, and by 2 to 3 times higher at ages 41 to 61 years, which suggests that the impact of diabetes on CAD was markedly greater in younger men compared with men in middle age Thus, prevention of ASCVD in addition to microvascular disease is quite important issue even in Japanese diabetic subjects As the risk of these composite outcomes differs greatly depending on the cause, GFR and amount of proteinuria albuminuria , the severity of CKD is classified CGA classification , using these three primary factors.

In the screening for CKD , urinary protein and urinary occult blood are assessed by a qualitative urine test, and eGFR is determined by measuring serum creatinine levels. Whenever necessary, the degree of proteinuria is further determined quantitatively using the casual spot urinary protein-to-creatinine ratio. CKD may include conditions for which diagnosis by kidney biopsy is preferable so as to treat for remission, conditions requiring urgent treatment immune suppression therapy with corticosteroids, immune suppressants, molecular-targeted agents, or in combination , and also conditions that may need specialized medical care with renal replacement therapy such as renal transplantation and dialysis.

On top of that, non-traditional risk factors, such as abnormal phosphate-calcium metabolism play roles in advanced stages of CKD, and the relative contributions of certain risk factors for ASCVD are altered. This finding is consistent with the results of randomized controlled trials revealing that the use of statin did not decrease the risk for ASCVD significantly in dialysis patients , , suggesting the importance of implementing effective measures on patients with earlier stages of CKD.

Women have a lower risk for MI and MI-related death than men, but the gender difference decreases with aging.

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Evidence level: E In terms of absolute risk, aging enhances the risk for ASCVD and death from it much more than any other risk factors — Women have a lower risk for MI and MI-related death than men. In a survey conducted in Takashima town, Shiga Prefecture from to , the age-adjusted incidence rate of acute MI , person-years was Furthermore, according to the vital statistics of , the approximate rate of mortality due to ischemic heart disease in a target population of , is The mortality rates target population of , according to age are as follows: 2.

The mortality rate of ischemic heart disease was lower in the women than men in all age groups. However, the mortality rate of ischemic heart disease for women starts increasing when they reach the 60s. Women in the 70s have a mortality rate that is almost the same as men in the 60s, which goes to show that the risk for ASCVD is not low for elderly women There was almost no difference between the mortality rates of cerebral infarction for men and women target population of , , which were The mortality rates target population of , according to age are: 0.

Up to the 90s age group, the mortality rate of cerebral infarction was lower in women than men. It has been reported in the Western countries since s that a family history of CAD is a risk factor for the disease itself — After adjusting all the variables in the multivariate analysis, the ratios were 2. Traditional risk factors high LDL-C, low HDL-C, hypertension, diabetes, and smoking are associated with genetic predisposition and are influenced by habits within the family.

In other words, a family history of CAD is considered to also include genetic and environmental risk factors, a fact that is already known. There has been attention on other risk factors that should be considered, such as Lp a , small dense LDL and homocysteine, which are all genetically regulated. However, it is assumed that unknown genetic factors play a role as family history remains a strong risk factor even after adjusting all the traditional risk factors in multivariate analyses 80 , — , , Therefore, most studies relating to family history have concluded that a family history of CAD is an independent risk factor for CAD. A history of CAD poses a higher risk compared to primary prevention. It is evident in epidemiological studies and intervention trials conducted in the Western countries that the incidence rate of cardiovascular events is higher in patients with CAD than in primary prevention patients — Similar results have also been reported in studies in Japan. The MEGA study, a primary prevention trial involving the use of statin 41 , showed that the incidence rate of cardiovascular events for the group that underwent diet therapy was 2.

In the J-LIT study, the incidence rate in primary prevention patients was 0. A history of noncardiogenic cerebral infarction is a high-risk condition for cerebrovascular disease and CAD. Patients with a history of cerebrovascular disease are known to be a high-risk group for CAD. In Japan, there has been reports revealing that the 1-year incidence rate for patients with a history of stroke is 0. Patients in Japan who have a history of stroke are considered to be at a high risk for developing CAD, especially those with noncardiogenic cerebral infarction originating from arteriosclerotic lesions.

In addition, findings of arteriosclerosis in the carotid arteries are an independent risk factor for CVD 6 , 8. It has been reported that an increase in the intima-media thickness IMT of common carotid arteries is particularly a significant predictive factor in cerebral infarction and CAD — However, it was reported in the results of a meta-analysis that both CVD and stroke were not seen to be significantly correlated with the progress of IMT On the other hand, it has been reported that the incidence rate of cerebrovascular disease is higher than the recurrence rate of CAD in patients with a history of CAD.

Moreover, the risk of developing cerebrovascular disease is also higher than the risk of CAD in those with a history of PAD Therefore, a history of cerebrovascular disease is something that should be taken note of. It mainly refers to diseases based on stenosis and obstructive lesions in the arteries of the lower extremities due to atherosclerosis. Coldness in the lower extremities, intermittent claudication, ulcers, and necrosis are some of the symptoms observed in PAD. Similar reports have also been surfacing in Japan recently. The results showed that the risk for developing CAD was 4.

The CIRCS study was another study that involved ordinary citizens, in which subjects who were 60—74 years old and did not suffer from CVD were followed up for an average of 9. The resulting incidence rates were generally high - 1. A prospective observational study was conducted on patients with PAD by Shigematsu et al. It was observed in the study that the three-year incidence rate was 6. Atherosclerotic disease often coexists in patients with AAA.

A survey conducted by Akai et al.

Hollier et al. There are currently no papers relating to studies on the long-term prognosis of patients with AAA in Japan.

Mr Tachibana and Dr Ikeda 21 (Japanese Edition) Mr Tachibana and Dr Ikeda 21 (Japanese Edition)
Mr Tachibana and Dr Ikeda 21 (Japanese Edition) Mr Tachibana and Dr Ikeda 21 (Japanese Edition)
Mr Tachibana and Dr Ikeda 21 (Japanese Edition) Mr Tachibana and Dr Ikeda 21 (Japanese Edition)
Mr Tachibana and Dr Ikeda 21 (Japanese Edition) Mr Tachibana and Dr Ikeda 21 (Japanese Edition)
Mr Tachibana and Dr Ikeda 21 (Japanese Edition) Mr Tachibana and Dr Ikeda 21 (Japanese Edition)
Mr Tachibana and Dr Ikeda 21 (Japanese Edition) Mr Tachibana and Dr Ikeda 21 (Japanese Edition)
Mr Tachibana and Dr Ikeda 21 (Japanese Edition) Mr Tachibana and Dr Ikeda 21 (Japanese Edition)
Mr Tachibana and Dr Ikeda 21 (Japanese Edition) Mr Tachibana and Dr Ikeda 21 (Japanese Edition)

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