Examinando por Autor "O’Donnell, Martin J."
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- PublicaciónAcceso abiertoAlcohol consumption and cardiovascular disease, cancer, injury, admission to hospital, and mortality : A prospective cohort study(2015-10-14) Smyth, Andrew; Teo, Koon; Rangarajan, Sumathy; O’Donnell, Martin J.; Zhang, Xiaohe; Rana, Punam; Leong, Darryl P.; Dagenais, Gilles; Seron, Pamela; Rosengren, Annika; Schutte, Aletta Elisabeth; Lopez-Jaramillo, Patricio; Oguz, Ayetkin; Chifamba, Jephat; Diaz, Rafael; Lear, Scott A.; Avezum, Alvaro; Kumar, Rajesh; Mohan, Viswanathan; Szuba, Andrzej; Wei, Li; Yang, Wang; Jian, Bo; McKee, Martin; Yusuf, Salim; The PURE (Prospective Urban Rural Epidemiology) Study investigatorsBackground Alcohol consumption is proposed to be the third most important modifiable risk factor for death and disability. However, alcohol consumption has been associated with both benefits and harms, and previous studies were mostly done in high-income countries. We investigated associations between alcohol consumption and outcomes in a prospective cohort of countries at different economic levels in five continents. Methods We included information from 12 countries participating in the Prospective Urban Rural Epidemiological (PURE) study, a prospective cohort study of individuals aged 35–70 years. We used Cox proportional hazards regression to study associations with mortality (n=2723), cardiovascular disease (n=2742), myocardial infarction (n=979), stroke (n=817), alcohol-related cancer (n=764), injury (n=824), admission to hospital (n=8786), and for a composite of these outcomes (n=11 963). Findings We included 114 970 adults, of whom 12 904 (11%) were from high-income countries (HICs), 24 408 (21%) were from upper-middle-income countries (UMICs), 48 845 (43%) were from lower-middle-income countries (LMICs), and 28 813 (25%) were from low-income countries (LICs). Median follow-up was 4·3 years (IQR 3·0–6·0). Current drinking was reported by 36 030 (31%) individuals, and was associated with reduced myocardial infarction (hazard ratio [HR] 0·76 [95% CI 0·63–0·93]), but increased alcohol-related cancers (HR 1·51 [1·22–1·89]) and injury (HR 1·29 [1·04–1·61]). High intake was associated with increased mortality (HR 1·31 [1·04–1·66]). Compared with never drinkers, we identified significantly reduced hazards for the composite outcome for current drinkers in HICs and UMICs (HR 0·84 [0·77–0·92]), but not in LMICs and LICs, for which we identified no reductions in this outcome (HR 1·07 [0·95–1·21]; pinteraction<0·0001). Interpretation Current alcohol consumption had differing associations by clinical outcome, and differing associations by income region. However, we identified sufficient commonalities to support global health strategies and national initiatives to reduce harmful alcohol use. Funding Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.
- PublicaciónRestringidoAssociation of urinary sodium excretion with blood pressure and cardiovascular clinical events in 17,033 Latin americans(2016-07) Lamelas, Pablo M.; Mente, Andrew; Diaz, Rafael; Orlandini, Andres; Avezum, Alvaro; Oliveira, Gustavo; Lanas, Fernando; Seron, Pamela; Lopez-Jaramillo, Patricio; Camacho López, Paul Anthony; O’Donnell, Martin J.; Rangarajan, Sumathy; Teo, Koon; Yusuf, SalimBACKGROUND: Information on actual sodium intake and its relationships with blood pressure (BP) and clinical events in South America is limited. The aim of this cohort study was to assess the relationship of sodium intake with BP, cardiovascular (CV) events, and mortality in South America. METHODS: We studied 17,033 individuals, aged 35–70 years, from 4 South American countries (Argentina, Brazil, Chile, and Colombia). Measures of sodium excretion, estimated from morning fasting urine, were used as a surrogate for daily sodium intake. We measured BP and monitored the composite outcome of death and major CV events. RESULTS: Overall mean sodium excretion was 4.70±1.43g/day. A positive, nonuniform association between sodium and BP was detected, with a significant steeper slope for the relationship at higher sodium excretion levels ( P < 0.001 for interaction). With a median follow-up of 4.7 years, the primary composite outcome (all-cause death, myocardial infarction, stroke, or heart failure) occurred in 568 participants (3.4%). Compared with sodium excretion of 5–6g/day (reference group), participants who excreted >7g/day had increased risks of the primary outcome (odds ratio (OR) 1.73; 95% confidence interval (CI) 1.24 to 2.40; P < 0.001), as well as death from any cause (OR 1.87; 95% CI 1.23 to 2.83; P = 0.003) and major CV disease (OR 1.77; 95% CI 1.12 to 2.81; P = 0.014). Sodium excretion of <3g/day was associated with a statistically nonsignificant increased risk of the primary outcome (OR 1.20; 95% CI 0.86 to 1.65; P = 0.26) and death from any cause (OR 1.25; 95% CI 0.81 to 1.93; P = 0.29), and a significant increased risk of major CV disease (OR 1.50; 95% CI 1.01 to 2.24; P = 0.048), as compared to the reference group. CONCLUSIONS: Our results support a positive, nonuniform association between estimated urinary sodium excretion and BP, and a possible J-shaped pattern of association between sodium excretion over the entire range and clinical outcomes.
- PublicaciónAcceso abiertoAssociations of urinary sodium excretion with cardiovascular events in individuals with and without hypertension : A pooled analysis of data from four studies(2016-07-30) Mente, Andrew; O’Donnell, Martin J.; Rangarajan, Sumathy; Dagenais, Gilles; Lear, Scott A.; McQueen, Matthew J.; Diaz, Rafael; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Lanas, Fernando; Li, Wei; Lu, Yin; Yi, Sun; Rensheng, Lei; Iqbal, Romaina; Mony, Prem; Yusuf, Rita; Yusoff, Khalid; Szuba, Andrzej; Oguz, Aytekin; Rosengren, Annika; Bahonar, Ahmad; Yusufali, Afzalhussein; Schutte, Aletta Elisabeth; Chifamba, Jephat; Mann, Johannes F. E.; Anand, Sonia S.; Teo, Koon; Yusuf, Salim; The PURE, EPIDREAM, and ONTARGET/TRANSCEND InvestigatorsBackground: Several studies reported a U-shaped association between urinary sodium excretion and cardiovascular disease events and mortality. Whether these associations vary between those individuals with and without hypertension is uncertain. We aimed to explore whether the association between sodium intake and cardiovascular disease events and all-cause mortality is modified by hypertension status. Methods: In this pooled analysis, we studied 133118 individuals (63559 with hypertension and 69559 without hypertension), median age of 55 years (IQR 45–63), from 49 countries in four large prospective studies and estimated 24-h urinary sodium excretion (as group-level measure of intake). We related this to the composite outcome of death and major cardiovascular disease events over a median of 4·2 years (IQR 3·0–5·0) and blood pressure. Findings: Increased sodium intake was associated with greater increases in systolic blood pressure in individuals with hypertension (2·08 mm Hg change per g sodium increase) compared with individuals without hypertension (1·22 mm Hg change per g; pinteraction<0·0001). In those individuals with hypertension (6835 events), sodium excretion of 7 g/day or more (7060 [11%] of population with hypertension: hazard ratio [HR] 1·23 [95% CI 1·11–1·37]; p<0·0001) and less than 3 g/day (7006 [11%] of population with hypertension: 1·34 [1·23–1·47]; p<0·0001) were both associated with increased risk compared with sodium excretion of 4–5 g/day (reference 25% of the population with hypertension). In those individuals without hypertension (3021 events), compared with 4–5 g/day (18508 [27%] of the population without hypertension), higher sodium excretion was not associated with risk of the primary composite outcome (≥7 g/day in 6271 [9%] of the population without hypertension; HR 0·90 [95% CI 0·76–1·08]; p=0·2547), whereas an excretion of less than 3 g/day was associated with a significantly increased risk (7547 [11%] of the population without hypertension; HR 1·26 [95% CI 1·10–1·45]; p=0·0009). Interpretation: Compared with moderate sodium intake, high sodium intake is associated with an increased risk of cardiovascular events and death in hypertensive populations (no association in normotensive population), while the association of low sodium intake with increased risk of cardiovascular events and death is observed in those with or without hypertension. These data suggest that lowering sodium intake is best targeted at populations with hypertension who consume high sodium diets. Funding: Full funding sources listed at end of paper (see Acknowledgments).
- PublicaciónAcceso abiertoGlobal and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE) : A case-control study(2016-07-15) O’Donnell, Martin J.; Chin, Siu Lim; Rangarajan, Sumathy; Xavier, Denis; Liu, Lisheng; Zhang, Hongye; Rao Melacini, Purnima; Zhang, Xiaohe; Pais, Prem; Agapay, Steven; Lopez-Jaramillo, Patricio; Damasceno, Albertino; Langhorne, Peter; McQueen, Matthew J.; Rosengren, Annika; Dehghan, Mahshid; Hankey, Graeme J.; Dans, Antonio; ElSayed, Ahmed; Avezum, Alvaro; Mondo, Charles; Diener, Hans Christoph; Ryglewicz, Danuta; Czlonkowska, Anna; Pogosova, Nana; Weimar, Christian; Iqbal, Romaina; Diaz, Rafael; Yusoff, Khalid; Yusufali, Afzalhussein; Oguz, Aytekin; Wang, Xingyu; Penaherrera, Ernesto; Lanas, Fernando; Ogah, Okechukwu S.; Ogunniyi, Adesola; Iversen, Helle K.; Malaga, German; Rumboldt, Zvonko; Oveisgharan, Shahram; Hussain, Fawaz Al; Magazi, Daliwonga; Nilanont, Yongchai; Ferguson, John; Paré, Guillaume; Yusuf, Salim; INTERSTROKE investigatorsBackground Stroke is a leading cause of death and disability, especially in low-income and middle-income countries. We sought to quantify the importance of potentially modifiable risk factors for stroke in different regions of the world, and in key populations and primary pathological subtypes of stroke. Methods We completed a standardised international case-control study in 32 countries in Asia, America, Europe, Australia, the Middle East, and Africa. Cases were patients with acute first stroke (within 5 days of symptom onset and 72 h of hospital admission). Controls were hospital-based or community-based individuals with no history of stroke, and were matched with cases, recruited in a 1:1 ratio, for age and sex. All participants completed a clinical assessment and were requested to provide blood and urine samples. Odds ratios (OR) and their population attributable risks (PARs) were calculated, with 99% confidence intervals. Findings Between Jan 11, 2007, and Aug 8, 2015, 26 919 participants were recruited from 32 countries (13 447 cases [10 388 with ischaemic stroke and 3059 intracerebral haemorrhage] and 13 472 controls). Previous history of hypertension or blood pressure of 140/90 mm Hg or higher (OR 2·98, 99% CI 2·72–3·28; PAR 47·9%, 99% CI 45·1–50·6), regular physical activity (0·60, 0·52–0·70; 35·8%, 27·7–44·7), apolipoprotein (Apo)B/ApoA1 ratio (1·84, 1·65–2·06 for highest vs lowest tertile; 26·8%, 22·2–31·9 for top two tertiles vs lowest tertile), diet (0·60, 0·53–0·67 for highest vs lowest tertile of modified Alternative Healthy Eating Index [mAHEI]; 23·2%, 18·2–28·9 for lowest two tertiles vs highest tertile of mAHEI), waist-to-hip ratio (1·44, 1·27–1·64 for highest vs lowest tertile; 18·6%, 13·3–25·3 for top two tertiles vs lowest), psychosocial factors (2·20, 1·78–2·72; 17·4%, 13·1–22·6), current smoking (1·67, 1·49–1·87; 12·4%, 10·2–14·9), cardiac causes (3·17, 2·68–3·75; 9·1%, 8·0–10·2), alcohol consumption (2·09, 1·64–2·67 for high or heavy episodic intake vs never or former drinker; 5·8%, 3·4–9·7 for current alcohol drinker vs never or former drinker), and diabetes mellitus (1·16, 1·05–1·30; 3·9%, 1·9–7·6) were associated with all stroke. Collectively, these risk factors accounted for 90·7% of the PAR for all stroke worldwide (91·5% for ischaemic stroke, 87·1% for intracerebral haemorrhage), and were consistent across regions (ranging from 82·7% in Africa to 97·4% in southeast Asia), sex (90·6% in men and in women), and age groups (92·2% in patients aged ≤55 years, 90·0% in patients aged >55 years). We observed regional variations in the importance of individual risk factors, which were related to variations in the magnitude of ORs (rather than direction, which we observed for diet) and differences in prevalence of risk factors among regions. Hypertension was more associated with intracerebral haemorrhage than with ischaemic stroke, whereas current smoking, diabetes, apolipoproteins, and cardiac causes were more associated with ischaemic stroke (p<0·0001). Interpretation Ten potentially modifiable risk factors are collectively associated with about 90% of the PAR of stroke in each major region of the world, among ethnic groups, in men and women, and in all ages. However, we found important regional variations in the relative importance of most individual risk factors for stroke, which could contribute to worldwide variations in frequency and case-mix of stroke. Our findings support developing both global and region-specific programmes to prevent stroke. Funding Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Health Research Board Ireland, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland (Sweden), AstraZeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MSD, Chest, Heart and Stroke Scotland, and The Stroke Association, with support from The UK Stroke Research Network.
- PublicaciónRestringidoJoint association of urinary sodium and potassium excretion with cardiovascular events and mortality : Prospective cohort study(BMJ (Online), 2019, 2019-03-13) O’Donnell, Martin J.; Mente, Andrew; Rangarajan, Sumathy; McQueen, Matthew J.; O’Leary, Neil; Yin, Lu; Liu, Xiaoyun; Swaminathan, Sumathi; Khatib, Rasha; Rosengren, Annika; Ferguson, John; Smyth, Andrew; Lopez-Jaramillo, Patricio; Diaz, Rafael; Avezum, Alvaro; Lanas, Fernando; Ismail, Noorhassim; Yusoff, Khalid; Dans, Antonio; Iqbal, Romaina; Szuba, Andrzej; Mohammadifard, Noushin; Oguz, Atyekin; Hussein Yusufali, Afzal; AlHabib, Khalid F.; Kruger, Iolanthe Marike; Yusuf, Rita; Chifamba, Jephat; Yeates, Karen; Dagenais, Gilles; Wielgosz, Andreas; Lear, Scott A.; Teo, Koon; Yusuf, SalimObjective To evaluate the joint association of sodium and potassium urinary excretion (as surrogate measures of intake) with cardiovascular events and mortality, in the context of current World Health Organization recommendations for daily intake (<2.0 g sodium, >3.5 g potassium) in adults. Design International prospective cohort study. Setting 18 high, middle, and low income countries, sampled from urban and rural communities. Participants 103 570 people who provided morning fasting urine samples. Main outcome measures Association of estimated 24 hour urinary sodium and potassium excretion (surrogates for intake) with all cause mortality and major cardiovascular events, using multivariable Cox regression. A six category variable for joint sodium and potassium was generated: sodium excretion (low (<3 g/day), moderate (3-5 g/day), and high (>5 g/day) sodium intakes) by potassium excretion (greater/equal or less than median 2.1 g/day). Results Mean estimated sodium and potassium urinary excretion were 4.93 g/day and 2.12 g/day, respectively. After a median follow-up of 8.2 years, 7884 (6.1%) participants had died or experienced a major cardiovascular event. Increasing urinary sodium excretion was positively associated with increasing potassium excretion (unadjusted r=0.34), and only 0.002% had a concomitant urinary excretion of <2.0 g/day of sodium and >3.5 g/day of potassium. A J-shaped association was observed of sodium excretion and inverse association of potassium excretion with death and cardiovascular events. For joint sodium and potassium excretion categories, the lowest risk of death and cardiovascular events occurred in the group with moderate sodium excretion (3-5 g/day) and higher potassium excretion (21.9% of cohort). Compared with this reference group, the combinations of low potassium with low sodium excretion (hazard ratio 1.23, 1.11 to 1.37; 7.4% of cohort) and low potassium with high sodium excretion (1.21, 1.11 to 1.32; 13.8% of cohort) were associated with the highest risk, followed by low sodium excretion (1.19, 1.02 to 1.38; 3.3% of cohort) and high sodium excretion (1.10, 1.02 to 1.18; 29.6% of cohort) among those with potassium excretion greater than the median. Higher potassium excretion attenuated the increased cardiovascular risk associated with high sodium excretion (P for interaction=0.007). Conclusions These findings suggest that the simultaneous target of low sodium intake (<2 g/day) with high potassium intake (>3.5 g/day) is extremely uncommon. Combined moderate sodium intake (3-5 g/day) with high potassium intake is associated with the lowest risk of mortality and cardiovascular events.
- PublicaciónRestringidoMendelian Genes and Risk of Intracerebral Hemorrhage and Small-Vessel Ischemic Stroke in Sporadic Cases(2017-08) Lopez-Jaramillo, Patricio; Chong, Michael; O’Donnell, Martin J.; Thijs, Vincent; Dans, Antonio; Gómez Arbeláez, Diego; Mondo, Charles; Czlonkowska, Anna; Skowronska, Marta; Oveisgharan, Shahram; Yusuf, Salim; Paré, GuillaumeBackground and Purpose—Mendelian strokes are rare genetic disorders characterized by early-onset small-vessel stroke. Although extensively studied among families with syndromic features, whether these genes affect risk among sporadic cases is unknown. Methods—We sequenced 8 genes responsible for Mendelian stroke in a case–control study of sporadic stroke cases (≤70 years). Participants included 1251 primary stroke cases of small-vessel pathology (637 intracerebral hemorrhage and 614 small-vessel ischemic stroke cases) and 1716 controls from the INTERSTROKE study (Study of the Importance of Conventional and Emerging Risk Factors of Stroke in Different Regions and Ethnic Groups of the World). Results—Overall, the prevalence of canonical disease-causing mutations was 0.56% in cases and 0.23% in controls (odds ratio=1.89; 95% confidence interval, 0.54–7.57; P=0.33). CADASIL (Cerebral Autosomal Dominant Arteriopathies with Subcortical Infarcts and Leukoencephalopathies) mutations were more frequent among cases (0.48%) than controls (0.23%) but were not significantly associated with stroke risk (odds ratio=2.03; 95% confidence interval, 0.58–8.02; P=0.27). Next, we included all rare nonsynonymous mutations to investigate whether other types of mutations may contribute to stroke risk. Overall, 13.5% of cases and 14.2% of controls were carriers of at least one rare nonsynonymous mutation among the 8 Mendelian stroke genes. Mutation carriers were not at elevated risk of stroke (odds ratio=0.93; 95% confidence interval, 0.75–1.16; P=0.55). Conclusions—In the absence of syndromic features and family history of stroke, screening for Mendelian mutations among small-vessel stroke patients is unlikely to have high diagnostic utility.
- PublicaciónRestringidoPeripheral Blood MCEMP1 Gene Expression as a Biomarker for Stroke Prognosis(2016-01-12) Lopez-Jaramillo, Patricio; Raman, Kripa; O’Donnell, Martin J.; Czlonkowska, Anna; Duarte, Yan Carlos; Peñaherrera, Ernesto; Sharma, Mike; Shoamanesh, Ashkan; Skowronska, Marta; Yusuf, Salim; Paré, GuillaumeBackground and Purpose—A limitation when making early decisions on stroke management is the lack of rapid diagnostic and prognostic testing. Our study sought to identify peripheral blood RNA biomarkers associated with stroke. The secondary aims were to assess the discriminative capacity of RNA biomarkers for primary stroke type and stroke prognosis at 1-month. Methods—Whole-blood gene expression profiling was conducted on the discovery cohort: 129 first-time stroke cases that had blood sampling within 5 days of symptom onset and 170 control participants with no history of stroke. Results—Through multiple regression analysis, we determined that expression of the gene MCEMP1 had the strongest association with stroke of 11181 genes tested. MCEMP1 increased by 2.4-fold in stroke when compared with controls (95% confidence interval, 2.0–2.8; P=8.2×10−22). In addition, expression was elevated in intracerebral hemorrhage when compared with ischemic stroke cases (P=3.9×10−4). MCEMP1 was also highest soon after symptom onset and had no association with stroke risk factors. Furthermore, MCEMP1 expression independently improved discrimination of 1-month outcome. Indeed, discrimination models for disability and mortality that included MCEMP1 expression, baseline modified Rankin Scale score, and primary stroke type improved discrimination when compared with a model without MCEMP1 (disability Net Reclassification Index, 0.76; P=3.0×10−6 and mortality Net Reclassification Index, 1.3; P=1.1×10−9). Significant associations with MCEMP1 were confirmed in an independent validation cohort of 28 stroke cases and 34 controls. Conclusions—This study demonstrates that peripheral blood expression of MCEMP1 may have utility for stroke diagnosis and as a prognostic biomarker of stroke outcome at 1-month.
- PublicaciónAcceso abiertoRenal Impairment and Risk of Acute Stroke: The INTERSTROKE Study(Karger Publishers, 2021-05-05) Smyth, Andrew; Judge, Conor; Wang, Xingyu; Pare, Guillaume; Rangarajan, Sumathy; Canavan, Michelle; Chin, Siu Lim; Al-Hussain, F.; Yusufali, Afzalhussein; ElSayed, Ahmed; Damasceno, Albertino; Avezum, Alvaro; Czlonkowska, Anna; Rosengren, Annika; Dans, Antonio; Oguz, Aytekin; Mondo, Charles; Weimar, Christian; Ryglewicz, Danuta; Xavier, Denis; Lanas, Fernando; Malaga, German; Hankey, Graeme J.; Iversen, Helle K.; Zhang, Hongye; Yusoff, Khalid; Pogosova, Nana; Lopez-Jaramillo, Patricio; Langhorne, Peter; Diaz, Rafael; Oveisgharan, Shahram; Yusuf, Salim; O’Donnell, Martin J.; The INTERSTROKE investigators; MasiraBackground: Previous studies reported an association of renal impairment with stroke, but there are uncertainties underpinning this association. Aims: We explored if the association is explained by shared risk factors or is independent and whether there are regional or stroke subtype variations. Methods: INTERSTROKE is a case-control study and the largest international study of risk factors for first acute stroke, completed in 27 countries. We included individuals with available serum creatinine values and calculated estimated glomerular filtration rate (eGFR). Renal impairment was defined as eGFR <60 mL/min/1.73 m2. Multivariable conditional logistic regression was used to determine the association of renal function with stroke. Results: Of 21,127 participants, 41.0% were female, the mean age was 62.3 ± 13.4 years, and the mean eGFR was 79.9 ± 23.5 mL/min/1.73 m2. The prevalence of renal impairment was higher in cases (22.9% vs. 17.7%, p < 0.001) and differed by region (p < 0.001). After adjustment, lower eGFR was associated with increased odds of stroke. Renal impairment was associated with increased odds of all stroke (OR 1.35; 95% CI: 1.24–1.47), with higher odds for intracerebral hemorrhage (OR 1.60; 95% CI: 1.35–1.89) than ischemic stroke (OR 1.29; 95% CI: 1.17–1.42) (pinteraction 0.12). The largest magnitudes of association were seen in younger participants and those living in Africa, South Asia, or South America (pinteraction < 0.001 for all stroke). Renal impairment was also associated with poorer clinical outcome (RRR 2.97; 95% CI: 2.50–3.54 for death within 1 month). Conclusion: Renal impairment is an important risk factor for stroke, particularly in younger patients, and is associated with more severe stroke and worse outcomes.
- PublicaciónAcceso abiertoUrinary sodium and potassium excretion, mortality, and cardiovascular events(2014-08-14) O’Donnell, Martin J.; Mente, Andrew; Rangarajan, Sumathy; McQueen, Matthew J.; Wang, Xingyu; Liu, Lisheng; Yan, Hou; Lee, Shun Fu; Mony, Prem; Devanath, Anitha; Rosengren, Annika; Lopez-Jaramillo, Patricio; Diaz, Rafael; Avezum, Alvaro; Lanas, Fernando; Yusoff, Khalid; Iqbal, Romaina; Ilow, Rafal; Mohammadifard, Noushin; Gulec, Sadi; Yusufali, Afzalhussein; Kruger, Lanthe; Yusuf, Rita; Chifamba, Jephat; Kabali, Conrad; Dagenais, Gilles; Lear, Scott A.; Teo, Koon; Yusuf, Salim; The PURE (Prospective Urban Rural Epidemiology) Study investigatorsBACKGROUND The optimal range of sodium intake for cardiovascular health is controversial. METHODS We obtained morning fasting urine samples from 101,945 persons in 17 countries and estimated 24-hour sodium and potassium excretion (used as a surrogate for intake). We examined the association between estimated urinary sodium and potassium excretion and the composite outcome of death and major cardiovascular events. RESULTS The mean estimated sodium and potassium excretion were 4.93 g per day and 2.12 g per day, respectively. With a mean follow-up of 3.7 years, the composite outcome occurred in 3317 participants (3.3%). As compared with an estimated sodium excretion of 4.00 to 5.99 g per day (reference range), a higher estimated sodium excretion (≥7.00 g per day) was associated with an increased risk of the composite outcome (odds ratio, 1.15; 95% confidence interval [CI], 1.02 to 1.30), as well as increased risks of death and major cardiovascular events considered separately. The association between a high estimated sodium excretion and the composite outcome was strongest among participants with hypertension (P=0.02 for interaction). As compared with the reference range, an estimated sodium excretion that was below 3.00 g per day was also associated with an increased risk of the composite outcome (odds ratio, 1.27; 95% CI, 1.12 to 1.44). As compared with an estimated potassium excretion that was less than 1.50 g per day, higher potassium excretion was associated with a reduced risk of the composite outcome. CONCLUSIONS In this study in which sodium intake was estimated on the basis of measured urinary excretion, an estimated sodium intake between 3 g per day and 6 g per day was associated with a lower risk of death and cardiovascular events, as compared with either a higher or lower estimated level of intake. As compared with an estimate potassium excretion that was less than 1.50 g per day, higher potassium excretion was associated with a lower risk of death and cardiovascular events. (Funded by the Population Health Research Institute and others.)
- PublicaciónAcceso abiertoUrinary Sodium and Potassium, and Risk of Ischemic and Hemorrhagic Stroke (INTERSTROKE). A Case-Control Study(Oxford Academic, 2021-04-01) Judge, Conor; O’Donnell, Martin J.; Hankey, Graeme J.; Rangarajan, Sumathy; Lim Chin, Siu; Rao-Melacini, Purnima; Ferguson, John; Smyth, Andrew; Xavier, Denis; Lisheng, Liu; Zhang, Hongye; Lopez-Jaramillo, Patricio; Damasceno, Albertino; Langhorne, Peter; Rosengren, Annika; Dans, Antonio; Elsayed, Ahmed; Avezum, Alvaro; Mondo, Charles; Ryglewicz, Danuta; Czlonkowska, Anna; Pogosova, Nana; Weimar, Christian; Diaz, Rafael; Yusoff, Khalid; Yusufali, Afzalhussein; Oguz, Aytekin; Wang, Xingyu; Lanas, Fernando; Ogah, Okechukwu S.; Ogunniyi, Adesola; Iversen, Helle K.; Malaga, German; Rumboldt, Zvonko; Oveisgharan, Shahram; Hussain, Fawaz Al; Yusuf, Salim; INTERSTROKE investigators; MasiraBACKGROUND Although low sodium intake (<2 g/day) and high potassium intake (>3.5 g/day) are proposed as public health interventions to reduce stroke risk, there is uncertainty about the benefit and feasibility of this combined recommendation on prevention of stroke. METHODS We obtained random urine samples from 9,275 cases of acute first stroke and 9,726 matched controls from 27 countries and estimated the 24-hour sodium and potassium excretion, a surrogate for intake, using the Tanaka formula. Using multivariable conditional logistic regression, we determined the associations of estimated 24-hour urinary sodium and potassium excretion with stroke and its subtypes. RESULTS Compared with an estimated urinary sodium excretion of 2.8–3.5 g/day (reference), higher (>4.26 g/day) (odds ratio [OR] 1.81; 95% confidence interval [CI], 1.65–2.00) and lower (<2.8 g/day) sodium excretion (OR 1.39; 95% CI, 1.26–1.53) were significantly associated with increased risk of stroke. The stroke risk associated with the highest quartile of sodium intake (sodium excretion >4.26 g/day) was significantly greater (P < 0.001) for intracerebral hemorrhage (ICH) (OR 2.38; 95% CI, 1.93–2.92) than for ischemic stroke (OR 1.67; 95% CI, 1.50–1.87). Urinary potassium was inversely and linearly associated with risk of stroke, and stronger for ischemic stroke than ICH (P = 0.026). In an analysis of combined sodium and potassium excretion, the combination of high potassium intake (>1.58 g/day) and moderate sodium intake (2.8–3.5 g/day) was associated with the lowest risk of stroke. CONCLUSIONS The association of sodium intake and stroke is J-shaped, with high sodium intake a stronger risk factor for ICH than ischemic stroke. Our data suggest that moderate sodium intake—rather than low sodium intake—combined with high potassium intake may be associated with the lowest risk of stroke and expected to be a more feasible combined dietary target.
- PublicaciónAcceso abiertoVariations in risks from smoking between high-income, middle-income, and low-income countries. An analysis of data from 179 000 participants from 63 countries(The Lancet Global Health, 2022-02-24) Sathish, Thirunavukkarasu; Teo, Koon; Britz-McKibbin, Philip; Gill, Biban; Islam, Shofiqul; Pare, Guillaume; Rangarajan, Sumathy; Duong, MyLinh; Lanas, Fernando; Lopez-Jaramillo, Patricio; Mony, Prem; Pinnaka, Lakshmi; Raman Kutty, Vellappillil; Orlandini, Andres; Avezum, Alvaro; Wielgosz, Andreas; Poirier, Paul; Alhabib, Khalid F.; Temizhan, Ahmet; Chifamba, Jephat; Yeates, Karen; Kruger, Iolanthé M.; Khatib, Rasha; Yusuf, Rita; Rosengren, Annika; Zatonska, Katarzyna; Iqbal, Romaina; Lui, Weida; Lang, Xinyue; Li, Sidong; Hu, Bo; Dans, Antonio; Yusufali, Afzalhussein; Bahonar, Ahmad; O’Donnell, Martin J.; McKee, Martin; Yusuf, Salim; MasiraBackground Separate studies suggest that the risks from smoking might vary between high-income (HICs), middle-income (MICs), and low-income (LICs) countries, but this has not yet been systematically examined within a single study using standardised approaches. We examined the variations in risks from smoking across different country income groups and some of their potential reasons. Methods We analysed data from 134 909 participants from 21 countries followed up for a median of 11·3 years in the Prospective Urban Rural Epidemiology (PURE) cohort study; 9711 participants with myocardial infarction and 11 362 controls from 52 countries in the INTERHEART case-control study; and 11 580 participants with stroke and 11 331 controls from 32 countries in the INTERSTROKE case-control study. In PURE, all-cause mortality, major cardiovascular disease, cancers, respiratory diseases, and their composite were the primary outcomes for this analysis. Biochemical verification of urinary total nicotine equivalent was done in a substudy of 1000 participants in PURE. Findings In PURE, the adjusted hazard ratio (HR) for the composite outcome in current smokers (vs never smokers) was higher in HICs (HR 1·87, 95% CI 1·65–2·12) than in MICs (1·41, 1·34–1·49) and LICs (1·35, 1·25–1·46; interaction p<0·0001). Similar patterns were observed for each component of the composite outcome in PURE, myocardial infarction in INTERHEART, and stroke in INTERSTROKE. The median levels of tar, nicotine, and carbon monoxide displayed on the cigarette packs from PURE HICs were higher than those on the packs from MICs. In PURE, the proportion of never smokers reporting high second-hand smoke exposure (≥1 times/day) was 6·3% in HICs, 23·2% in MICs, and 14·0% in LICs. The adjusted geometric mean total nicotine equivalent was higher among current smokers in HICs (47·2 μM) than in MICs (31·1 μM) and LICs (25·2 μM; ANCOVA p<0·0001). By contrast, it was higher among never smokers in LICs (18·8 μM) and MICs (11·3 μM) than in HICs (5·0 μM; ANCOVA p=0·0001). Interpretation The variations in risks from smoking between country income groups are probably related to the higher exposure of tobacco-derived toxicants among smokers in HICs and higher rates of high second-hand smoke exposure among never smokers in MICs and LICs.
- PublicaciónAcceso abiertoVariations in risks from smoking between high-income, middle-income, and low-income countries: an analysis of data from 179 000 participants from 63 countries(2022-02-05) Sathish, Thirunavukkarasu; Teo, Koon K.; Britz-McKibbin, Philip; Gill, Biban; Islam, Shofiqul; Paré, Guillaume; Rangarajan, Sumathy; Duong, MyLinh; Lanas, Fernando; Lopez-Jaramillo, Patricio; Mony, Prem K.; Pinnaka, Lakshmi; Kutty, Vellappillil Raman; Orlandini, Andres; Avezum, Alvaro; Wielgosz, Andreas; Poirier, Paul; Alhabib, Khalid F.; Temizhan, Ahmet; Chifamba, Jephat; Yeates, Karen; Kruger, Iolanthé M.; Khatib, Rasha; Yusuf, Rita; Rosengren, Annika; Zatonska, Katarzyna; Iqbal, Romaina; Lui, Weida; Lang, Xinyue; Li, Sidong; Hu, Bo; Dans, Antonio L.; Yusufali, Afzal Hussein; Bahonar, Ahmad; O’Donnell, Martin J.; McKee, Martin; Yusuf, Salim; MasiraBackground Separate studies suggest that the risks from smoking might vary between high-income (HICs), middle-income (MICs), and low-income (LICs) countries, but this has not yet been systematically examined within a single study using standardised approaches. We examined the variations in risks from smoking across different country income groups and some of their potential reasons. Methods We analysed data from 134 909 participants from 21 countries followed up for a median of 11·3 years in the Prospective Urban Rural Epidemiology (PURE) cohort study; 9711 participants with myocardial infarction and 11 362 controls from 52 countries in the INTERHEART case-control study; and 11 580 participants with stroke and 11 331 controls from 32 countries in the INTERSTROKE case-control study. In PURE, all-cause mortality, major cardiovascular disease, cancers, respiratory diseases, and their composite were the primary outcomes for this analysis. Biochemical verification of urinary total nicotine equivalent was done in a substudy of 1000 participants in PURE. Findings In PURE, the adjusted hazard ratio (HR) for the composite outcome in current smokers (vs never smokers) was higher in HICs (HR 1·87, 95% CI 1·65–2·12) than in MICs (1·41, 1·34–1·49) and LICs (1·35, 1·25–1·46; interaction p<0·0001). Similar patterns were observed for each component of the composite outcome in PURE, myocardial infarction in INTERHEART, and stroke in INTERSTROKE. The median levels of tar, nicotine, and carbon monoxide displayed on the cigarette packs from PURE HICs were higher than those on the packs from MICs. In PURE, the proportion of never smokers reporting high second-hand smoke exposure (≥1 times/day) was 6·3% in HICs, 23·2% in MICs, and 14·0% in LICs. The adjusted geometric mean total nicotine equivalent was higher among current smokers in HICs (47·2 μM) than in MICs (31·1 μM) and LICs (25·2 μM; ANCOVA p<0·0001). By contrast, it was higher among never smokers in LICs (18·8 μM) and MICs (11·3 μM) than in HICs (5·0 μM; ANCOVA p=0·0001). Interpretation The variations in risks from smoking between country income groups are probably related to the higher exposure of tobacco-derived toxicants among smokers in HICs and higher rates of high second-hand smoke exposure among never smokers in MICs and LICs.