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Brief Communication
Association between cardiac arrhythmia before pregnancy and gestational diabetes: a nationwide population-based study in Korea
You-Jung Choi, Won Young Wi, Geum Joon Cho, Jin Oh Na
Epidemiol Health. 2023;45:e2023103.   Published online December 4, 2023
DOI: https://doi.org/10.4178/epih.e2023103
  • 2,151 View
  • 142 Download
AbstractAbstract AbstractSummary PDFSupplementary Material
Abstract
Given the higher prevalence of cardiac arrhythmias in individuals with diabetes, we investigated the relationship between cardiac arrhythmias and the incidence of gestational diabetes (GDM). This retrospective cohort study utilized data from the Korean Health Insurance Service database, encompassing 1,113,729 women who gave birth between January 2007 and December 2015. After excluding those who did not undergo National Health Screening tests within 1 year prior to pregnancy, those with multifetal pregnancies, and those diagnosed with diabetes, we analyzed 365,880 singleton pregnancies without a history of diabetes. Of these, 3,253 (0.9%) had cardiac arrhythmias, including premature extra beats, supraventricular tachyarrhythmias, and/or atrial flutter/fibrillation. GDM occurred in 31,938 (8.7%) subjects during pregnancy, and was more prevalent in women with cardiac arrhythmia than in those without (14.9 vs. 8.7%, p<0.001). In the multivariate analysis, the association between cardiac arrhythmia and GDM remained statistically significant (adjusted odds ratio, 1.78; 95% confidence interval, 1.61 to 1.97; p<0.001). Subgroup analysis revealed that the risk of GDM was consistently statistically significant in subjects with cardiac arrhythmia, regardless of age, body mass index, and the presence or absence of chronic hypertension. Therefore, cardiac arrhythmias before and during pregnancy appear to be associated with an increased risk of developing GDM.
Summary
Korean summary
본 연구에서는 부정맥과 임신성 당뇨병의 발생과의 관계를 확인인하기 위하여 2007년부터 2015년까지 국민건강보험 공단 데이터를 이용하여 분만력을 가진 1,113,729명의 여성을 대상으로 진행되었습니다. 최종 분석은 과거 당뇨병 진단병력을 가지고 있는 환자를 제외하고 365,880건의 단태아 임산부를 포함하였고, 전체 대상자 중 31,938 (8.7%)에서 임신성 당뇨병을 확인하였습니다. 그 중 부정맥 병력이 확인되지 않은 임산부와 비교하였을 때, 부정맥 병력이 있는 경우 임신 기간 중 임신성 당뇨병 발생률이 높았으며 (8.7% vs. 14.9%, p<0.001), 다변량 분석에서도 부정맥과 임신 당뇨병 간의 연관성이 통계적으로 유의미하게 나타났습니다 (adjusted odds ratio, 1.78; 95% confidence interval, 1.61 to 1.97; p<0.001). 따라서, 본 연구는 임신 전후의 부정맥 병력은 임신성 당뇨병 발병 위험 증가와 관련 있음을 시사합니다.
Key Message
This nationwide population-based cross-sectional study using the Korean Health Insurance Service database showed that women with a history of cardiac arrhythmia had an elevated risk of incident GDM during pregnancy. The prevalence of GDM was significantly higher in women with cardiac arrhythmias (8.7% vs. 14.9%). There was a statistically significant association between cardiac arrhythmia and GDM (adjusted odds ratio: 1.78), suggesting that cardiac arrhythmias before and during pregnancy are linked to an increased risk of developing GDM, independent of age, BMI, and chronic hypertension.
Original Articles
Association of blood pressure measurements in sitting, supine, and standing positions with the 10-year risk of mortality in Korean adults
Inkyung Baik, Nan Hee Kim, Seong Hwan Kim, Chol Shin
Epidemiol Health. 2023;45:e2023055.   Published online June 8, 2023
DOI: https://doi.org/10.4178/epih.e2023055
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  • 174 Download
  • 1 Web of Science
  • 1 Crossref
AbstractAbstract AbstractSummary PDFSupplementary Material
Abstract
OBJECTIVES
This prospective cohort study investigated the association between blood pressure (BP) as measured in different body postures and all-cause and cardiovascular (CV) mortality risk.
METHODS
This population-based investigation included 8,901 Korean adults in 2001 and 2002. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured sequentially in the sitting, supine, and standing positions and classified into 4 categories: (1) normal, SBP <120 mmHg and DBP <80 mmHg; (2) high normal/prehypertension, SBP 120-129 mmHg and DBP <80 mmHg/SBP 130-139 mmHg or DBP 80-89 mmHg; (3) grade 1 hypertension (HTN), with SBP 140-159 mmHg or DBP 90-99 mmHg; and (4) grade 2 HTN, SBP ≥160 mmHg or DBP ≥100 mmHg. The date and cause of individual deaths were confirmed in the death record data compiled until 2013. Data were analyzed using Cox proportional hazard regression.
RESULTS
Significant associations were found between the BP categories and all-cause mortality, but only when BPs were measured in the supine position. The multivariate hazard ratios (95% confidence intervals, [CIs]) were 1.36 (95% CI, 1.06 to 1.75) and 1.59 (95% CI, 1.06 to 2.39) for grade 1 HTN and grade 2 HTN, respectively, compared with the normal category. The associations between the BP categories and CV mortality were significant regardless of body posture among participants ≥65 years, whereas they were significant for supine BP measurements only in those <65 years.
CONCLUSIONS
BP measured in the supine position predicted all-cause mortality and CV mortality better than BP measured in other postures.
Summary
Korean summary
본 역학 연구는 한국 성인 8,901명을 연구대상자로 하여 기초조사에서 세가지 자세, 즉 앉은 자세, 누운 자세, 일어선 자세에서 혈압을 측정하고, 이후 10년 동안의 사망 여부를 추적조사하여, 측정 자세에 따른 혈압과 사망 위험과의 관련성을 분석하였다. 그 결과, 누운 자세에서 측정된 고혈압(기준: 수축기 혈압이 140 mmHg 이상 혹은 이완기 혈압이 90 mmHg 이상)인 사람은 정상 혈압(기준: 수축기 혈압이 120 mmHg 미만이고 이완기 혈압이 80 mmHg 미만)인 사람에 비해 36%(1단계 고혈압) 혹은 59%(2단계 고혈압) 가량 총 사망 위험이 유의적으로 증가하는 것으로 나타났다. 이에 비해, 앉은 자세 및 일어선 자세에서 측정, 정의된 고혈압은 총 사망 위험을 증가시켰지만 유의적인 결과를 나타내지 못했다. 추후 연구에서 재확인이 필요하지만, 본 연구 결과가 시사하는 바는 앉은 자세나 일어선 자세보다 누운 자세에서 측정하는 혈압이 총 사망 위험을 더 잘 예측하므로, 고혈압 진단 외의 추가적인 활용 가능성이 있는 것으로 평가된다.
Key Message
The current epidemiological study revealed that blood pressure measured in a supine position could predict all-cause mortality and cardiovascular mortality better than blood pressure measured in a sitting or standing position. As a result, blood pressure measurements in a supine position may be useful in assessing mortality risk.

Citations

Citations to this article as recorded by  
  • Safety of midodrine in patients with heart failure with reduced ejection fraction: a retrospective cohort study
    Ming-Ju Wu, Cheng-Hsu Chen, Shang-Feng Tsai
    Frontiers in Pharmacology.2024;[Epub]     CrossRef
Prediction of the 10-year risk of atherosclerotic cardiovascular disease in the Korean population
Sangwoo Park, Yong-Giun Kim, Soe Hee Ann, Young-Rak Cho, Shin-Jae Kim, Seungbong Han, Gyung-Min Park
Epidemiol Health. 2023;45:e2023052.   Published online May 12, 2023
DOI: https://doi.org/10.4178/epih.e2023052
  • 5,042 View
  • 216 Download
AbstractAbstract AbstractSummary PDFSupplementary Material
Abstract
OBJECTIVES
Proper risk assessment is important for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, no validated risk prediction tools are currently in use in Korea. This study sought to develop a 10-year risk prediction model for incident ASCVD.
METHODS
Using the National Sample Cohort of Korea, 325,934 subjects aged 20-80 years without previous ASCVD were enrolled. ASCVD was defined as a composite of cardiovascular death, myocardial infarction, and stroke. The Korean atherosclerotic cardiovas cular disease risk prediction (K-CVD) model was developed separately for men and women using the development dataset and validated in the validation dataset. Furthermore, the model performance was compared with the Framingham risk score (FRS) and pooled cohort equation (PCE).
RESULTS
Over 10 years of follow-up, 4,367 ASCVD events occurred in the overall population. The predictors of ASCVD included in the model were age, smoking status, diabetes, systolic blood pressure, lipid profiles, urine protein, and lipid-lowering and blood pressure-lowering treatment. The K-CVD model had good discrimination and strong calibration in the validation dataset (time-dependent area under the curve=0.846; 95% confidence interval, 0.828 to 0.864; calibration χ<sup>2</sup>=4.73, goodness-of-fit p=0.32). Compared with our model, both FRS and PCE showed worse calibration, overestimating ASCVD risk in the Korean population.
CONCLUSIONS
Through a nationwide cohort, we developed a model for 10-year ASCVD risk prediction in a contemporary Korean population. The K-CVD model showed excellent discrimination and calibration in Koreans. This population-based risk prediction tool would help to appropriately identify high-risk individuals and provide preventive interventions in the Korean population.
Summary
Korean summary
국민건강보험공단 표본 코호트를 이용하여, 한국인 인구에서 10년 죽상경화성 심혈관질환 위험 예측 (K-CVD) 모델을 개발하였다. 한국인 인구집단을 기반으로 개발된 K-CVD 모델은 한국 인구집단에서 판별력과 교정력 측면에서 우수한 성능을 보여주었다. K-CVD 모델은 한국인 집단에서 심혈관질환의 고위험군을 적절하게 식별하고, 예방적 중재를 시행하는데 있어 도움이 될 것으로 생각된다.
Key Message
Using a nationwide cohort, the Korean ASCVD risk prediction (K-CVD) model was developed for 10-year ASCVD risk prediction. The K-CVD model showed excellent discrimination and calibration in a contemporary Korean population. This population-based risk prediction tool would help to appropriately identify high-risk individuals and provide preventive interventions in the Korean population.
Risk of cancer, cardiovascular disease, thromboembolism, and mortality in patients with rheumatoid arthritis receiving Janus kinase inhibitors: a real-world retrospective observational study using Korean health insurance data
Hong Ki Min, Hyeongsu Kim, Ho Jin Jeong, Se Hee Kim, Hae-Rim Kim, Sang-Heon Lee, KunSei Lee, Soon-Ae Shin, Jong Heon Park
Epidemiol Health. 2023;45:e2023045.   Published online April 15, 2023
DOI: https://doi.org/10.4178/epih.e2023045
  • 6,138 View
  • 309 Download
  • 6 Web of Science
  • 5 Crossref
AbstractAbstract AbstractSummary PDFSupplementary Material
Abstract
OBJECTIVES
This study investigated whether Janus kinase inhibitors (JAKis) raise the risk of cardiovascular disease (CVD), venous thromboembolism (VTE), and cancer in patients with rheumatoid arthritis (RA).
METHODS
We conducted a real-world retrospective observational study using data obtained from the Korean National Health Insurance Service database. Two data sets were analyzed: tumor necrosis factor inhibitor (TNFi)/JAKi-naive RA patients (set 1) and all RA patients who used TNFis or JAKis (set 2). The incidence rate ratios (IRRs) and hazard ratios (HRs) for acute myocardial infarction (AMI), stroke, cardiovascular (CV)-related mortality, major adverse cardiovascular events (MACE), VTE, arterial thromboembolism (ATE), cancer, and all-cause mortality were compared between the JAKi and TNFi groups.
RESULTS
Set 1 included 1,596 RA patients (JAKi group: 645; TNFi group: 951), and set 2 included 11,765 RA patients (JAKi group: 2,498; TNFi group: 9,267). No adverse events (AEs) showed significantly higher IRRs in the JAKi groups than in the TNFi groups of sets 1 and 2. The HRs for MACE in the JAKi groups of sets 1 and 2 were 0.59 (95% confidence [CI], 0.35 to 0.99) and 0.80 (95% CI, 0.67 to 0.97), respectively. The JAKi group of set 2 showed a significantly higher risk of all-cause mortality (HR, 1.71; 95% CI, 1.32 to 2.20), but the other AEs did not demonstrate increased risks in the JAKi groups.
CONCLUSIONS
In this study, JAKis did not increase the risk of AMI, stroke, CV-related mortality, MACE, VTE, ATE, or cancer in Korean RA patients relative to TNFis.
Summary
Korean summary
1. 한국인 류마티스관절염 환자를 대상으로 한 실제임상자료 결과, JAK 억제제가 종양괴사인자 억제제에 비해 심혈관질환, 혈전증, 암 등의 심각한 부작용을 증가시키지는 않았다. 2. 본 연구를 토대로 한국인 대상자에서 JAK 억제제가 심혈관질환 등의 심각한 부작용을 증가시키는지에 대한 재평가가 필요하다.
Key Message
1. The real word-data based results showed that risks of MACE, thromboembolism, and cancers were not increased in Korean RA patients with JAK inhibitor when compared to Korean RA patients with TNF inhibitors. 2. Therefore, the risk of serious adverse events of JAK inhibitors in Korean population should be reconsidered and reassessed before adding black box warning of JAK inhibitors.

Citations

Citations to this article as recorded by  
  • Multicenter evaluation of tofacitinib retention and safety in rheumatoid arthritis – why cardiovascular risk factors do not equate to overt risk
    Anna Felis-Giemza, Mateusz Moskal, Krzysztof Proc, Zbigniew Guzera, Marcin Stajszczyk, Karolina Palej, Kornelia Chmurzyńska, Piotr Wiland, Krzysztof Batko, Bogdan Batko
    Rheumatology.2024; 61(6): 414.     CrossRef
  • Biologics Versus JAK Inhibitors. Part I: Cancer Risk. A Narrative Review
    Miguel Mansilla-Polo, Daniel Morgado-Carrasco
    Dermatology and Therapy.2024;[Epub]     CrossRef
  • Safety and Effectiveness of Baricitinib in Chinese Patients with Moderate-to-Severe Rheumatoid Arthritis: 24-Week Results from a Post-Marketing Safety Study
    Chan-yuan Wu, Qian Wang, Jian Shi, Xiu-ying Zhang, Rong Du, Jie-ruo Gu, Qi-huan Liu, Jiao Yu, Jia-wei Xu, Yan-jie Zhang, Hao Zhu, Meng-tao Li, Xiao-feng Zeng
    Rheumatology and Therapy.2023; 10(6): 1609.     CrossRef
  • Comparative cardiovascular safety with janus kinase inhibitors and biological disease-modifying antirheumatic drugs as used in clinical practice: an observational cohort study from Sweden in patients with rheumatoid arthritis
    Hannah Bower, Thomas Frisell, Daniela di Giuseppe, Benedicte Delcoigne, Johan Askling
    RMD Open.2023; 9(4): e003630.     CrossRef
  • Are JAKis more effective among elderly patients with RA, smokers and those with higher cardiovascular risk? A comparative effectiveness study of b/tsDMARDs in Sweden
    Hannah Bower, Thomas Frisell, Daniela di Giuseppe, Benedicte Delcoigne, Ulf Lindström, Carl Turesson, Katerina Chatzidionysiou, Elisabet Lindqvist, Ann Knight, Helena Forsblad-d'Elia, Johan Askling
    RMD Open.2023; 9(4): e003648.     CrossRef
Association of group-level segregation with cardiovascular health in older adults: an analysis of data from the Korean Social Life, Health, and Aging Project
Sung-Ha Lee, Hyeok-Hee Lee, Kiho Sung, Yoosik Youm, Hyeon Chang Kim
Epidemiol Health. 2023;45:e2023041.   Published online April 4, 2023
DOI: https://doi.org/10.4178/epih.e2023041
  • 5,788 View
  • 187 Download
  • 1 Web of Science
  • 1 Crossref
AbstractAbstract AbstractSummary PDFSupplementary Material
Abstract
OBJECTIVES
The adverse health effects of individual-level social isolation (e.g., perceived loneliness) have been well documented in older adults. However, little is known about the impact of collective-level social isolation on health outcomes. We sought to examine the association of group-level segregation with cardiovascular health (CVH) in older adults.
METHODS
From the prospective Korean Social Life, Health, and Aging Project database, we identified 528 community-dwelling older adults who were aged ≥60 years or were married to those aged ≥60 years. Participants who belonged to smaller social groups separate from the major social group were defined as group-level-segregated. The CVH score was calculated as the number of ideal non-dietary CVH metrics (0-6), as modified from the American Heart Association’s Life’s Simple 7. Using ordinal logistic regression models, we assessed cross-sectional and longitudinal associations between group-level segregation and CVH.
RESULTS
Of the 528 participants (mean age, 71.7 years; 60.0% female), 108 (20.5%) were segregated at baseline. In the crosssectional analysis, group-level segregation was significantly associated with lower odds of having a higher CVH score at baseline after adjusting for socio-demographic factors and cognitive function (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.43 to 0.95). Among 274 participants who completed an 8-year follow-up, group-level segregation at baseline was marginally associated with lower odds of having a higher CVH score at 8 years (OR, 0.49; 95% CI, 0.24 to 1.02).
CONCLUSIONS
Group-level segregation was associated with worse CVH. These findings imply that the social network structure of a community may influence its members’ health status.
Summary
Korean summary
본 연구는 “한국인의 사회적 삶, 건강과 노화에 대한 조사”(Korean Social Life, Health and Aging Project, KSHAP)에서 측정한 한 지역 내의 사회적 연결망 자료를 이용하여 사회적 분리와 심혈관 건강 사이의 관계를 살펴보았다. 그 결과, 사회적 분리는 비만, 고혈압, 콜레스테롤, 흡연, 음주 신체적 활동 등을 종합한 ‘라이프 심플 7’ 지표와 부정적인 관련성을 보였으며, 8년 후 추적 조사에서도 이 패턴이 유지되었다. 본 연구 결과는 사회적, 집단적 분리 현상이 신체적 건강에도 악영향을 초래할 수 있음을 시사한다.
Key Message
Using the prospective Korean Social Life, Health, and Aging Project (KSHAP) database, we discovered that group-level segregation was significantly associated with worse cardiovascular health (CVH). Also, we observed a tendency for baseline group-level segregation to be linked to worse CVH after an 8-year follow-up period. These findings emphasize the significance of group-level segregation as a potential contributing factor in the health outcomes of older adults.

Citations

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  • Association of social isolation and loneliness with the risk of hypertension in middle aged and older adults: Findings from a national representative longitudinal survey
    Shiqi Wang, Hao Zhang, Yiling Lou, Qiqi You, Qingqing Jiang, Shiyi Cao
    Journal of Affective Disorders.2024; 349: 577.     CrossRef
Impact of statin treatment on cardiovascular events in patients with retinal vein occlusion: a nested case-control study in Korea
Joonsang Yoo, Joo Youn Shin, Jimin Jeon, Jinkwon Kim
Epidemiol Health. 2023;45:e2023035.   Published online March 15, 2023
DOI: https://doi.org/10.4178/epih.e2023035
  • 4,027 View
  • 150 Download
  • 1 Web of Science
  • 1 Crossref
AbstractAbstract AbstractSummary PDFSupplementary Material
Abstract
OBJECTIVES
Retinal vein occlusion (RVO) is associated with an increased risk of future cardiovascular events. Statin therapy is a key cornerstone in prevention for patients at high cardiovascular risk. However, little is known about the role of statin therapy for patients with RVO. This study evaluated whether statin treatment in patients with RVO was associated with a lower risk of cardiovascular events.
METHODS
A population-based, nested case-control study was conducted with a cohort of newly diagnosed RVO patients without prior cardiovascular disease between 2008 and 2020 using a nationwide health claims database in Korea. From this cohort of RVO patients, we identified cases of cardiovascular events (stroke or myocardial infarction) after RVO and matched controls based on sex, age, insurance type, antiplatelet use, and underlying comorbidities using 1:2 incidence density sampling.
RESULTS
Using a cohort of 142,759 patients with newly diagnosed RVO, we selected 6,810 cases and 13,620 matched controls. A significantly lower risk of cardiovascular events (adjusted odds ratio, 0.604; 95% confidence interval, 0.557 to 0.655) was observed in RVO patients with statin treatment than in those without statin treatment. Statin treatment was associated with a reduced risk for both stroke and myocardial infarction after RVO. Longer statin treatment after RVO was associated with a lower risk for cardiovascular events.
CONCLUSIONS
Statin treatment was associated with a lower risk for future cardiovascular events in patients with newly diagnosed RVO. Further studies are warranted to clarify the potential cardiovascular preventive role of statins in patients with RVO.
Summary
Korean summary
· 망막정맥폐색 환자들은 심뇌혈관질환의 발생 위험이 높다고 알려져 있다. · 이번 연구를 통해 망막정맥폐색의 발생 이후 스타틴을 복용한 환자들에서 심근경색 및 뇌졸중 발생 위험도가 감소함을 확인하였다. · 고위험군인 망막정맥폐색 환자들에서 적극적인 스타틴의 사용이 심뇌혈관질환의 예방에 도움이 될 수 있을 것이다.
Key Message
· Statin was associated with a lower risk of cardiovascular events in RVO patients. · The reduced risk was observed in both stroke and myocardial infarction after RVO. · Statins might be a good candidate for cardiovascular prevention in RVO patients.

Citations

Citations to this article as recorded by  
  • Oclusión venosa de retina y su asociación con la enfermedad vascular aterosclerótica
    María Larrousse Morellón, Yéssica López Loureiro, Susana Ruiz Bilbao
    Medicina Clínica.2024;[Epub]     CrossRef
Physical activity, sedentary behavior, and cardiovascular disease risk in Korea: a trajectory analysis
Jina Han, Yeong Jun Ju, Soon Young Lee
Epidemiol Health. 2023;45:e2023028.   Published online February 22, 2023
DOI: https://doi.org/10.4178/epih.e2023028
  • 4,624 View
  • 236 Download
  • 1 Web of Science
  • 1 Crossref
AbstractAbstract PDF
Abstract
OBJECTIVES
To identify the distinct trajectories of sedentary behavior (SB) and explore whether reduced cardiovascular disease (CVD) risk was associated with a distinct trajectory of physical activity (PA).
METHODS
We analyzed data from 6,425 people who participated in the Korean Health Panel Survey over a period of 10 years. The participants’ self-reported SB and PA were assessed annually, and trajectory groups were identified using a group-based trajectory model for longitudinal data analysis. Logistic regression analysis was performed to assess the association between CVD risk (10-year cumulative incidence) and the trajectories of SB and PA. The adjusted variables included socio-demographic factors, the predisposing diseases of CVD, and baseline health behaviors.
RESULTS
Trajectory analysis identified 4 SB trajectory groups: SB group 1 (low and slightly increasing trend, 53.1%), SB group 2 (high and rapidly decreasing trend, 14.7%), SB group 3 (high and slightly decreasing trend, 9.9%), and SB group 4 (low and rapidly increasing trend, 22.2%). The 3 PA trajectory groups were PA group 1 (moderate and slightly decreasing trend, 32.1%), PA group 2 (low and slightly decreasing trend, 57.3%), and PA group 3 (maintained inactivity, 10.7%). By the 10-year follow-up, 577 cases of incident CVD had occurred. We also noted a 50% reduction in the risk of CVD when SB group 4 was accompanied by PA group 1 (odds ratio, 0.50; 95% confidence interval, 0.28 to 0.90).
CONCLUSIONS
Despite increased time spent in SB, maintaining PA about 2 days to 3 days per week reduced the occurrence of CVD.
Summary

Citations

Citations to this article as recorded by  
  • Effects of physical activity and sedentary behaviors on cardiovascular disease and the risk of all-cause mortality in overweight or obese middle-aged and older adults
    Yongqiang Zhang, Xia Liu
    Frontiers in Public Health.2024;[Epub]     CrossRef
A hypertension risk score for adults: a population-based cross-sectional study from the Dubai Household Survey 2019
Ibrahim Mahmoud, Nabil Sulaiman, Amal Hussein, Heba Mamdouh, Wafa K. AL Nakhi, Hamid Y. Hussain, Gamal M. Ibrahim
Epidemiol Health. 2021;43:e2021064.   Published online September 8, 2021
DOI: https://doi.org/10.4178/epih.e2021064
  • 18,675 View
  • 141 Download
AbstractAbstract AbstractSummary PDF
Abstract
OBJECTIVES
The aim of this study was to develop a risk score model for predicting hypertension specific to the population of Dubai in the United Arab Emirates (UAE) to facilitate prevention and early intervention.
METHODS
A retrospective analysis of data from the Dubai Household Health Survey 2019 was conducted. Demographic and physical parameters, as well as blood glucose levels, were included in the data. The risk factors for hypertension were identified using bivariate analysis. A risk score model was developed using the enter method, where all significant predictors of hypertension in bivariate analyses were entered in a single step with the primary outcome of hypertension status (yes/no). The model was validated internally by splitting the data into Emirati and non-Emirati populations.
RESULTS
A total of 2,533 subjects were studied. The significant risk factors for hypertension identified were male sex, older age (≥40 years), education level, body mass index, diabetes mellitus, and dyslipidaemia. The model showed a high discrimination ability between individuals with and without hypertension, with an area under the curve of 0.77 (95% confidence interval [CI], 0.75 to 0.79), excellent sensitivity (81.0%; 95% CI, 71.9 to 88.2) and moderate specificity (56.0%; 95% CI, 45.7 to 65.9).
CONCLUSIONS
The model developed by this study is simple, convenient, and based on readily available demographic and medical characteristics. This risk score model could support initial hypertension screening and provide an effective tool for targeted lifestyle counselling and prevention programs.
Summary
Key Message
To prevent hypertension in Dubai's adult population, primary health care physicians can use our risk score model to recommend preventative measures, with a focus on men over 40 years old, with a low educational level, who are obese, and who have other morbidities, such as diabetes mellitus and dyslipidemia.
Exploring the associations between cardiovascular health measured with the CANHEART model and early cognitive impairment in a middle-aged population in Korea
Ye Jin Jeon, Ji Heon Lee, Hyeon Chang Kim, Sun Jae Jung
Epidemiol Health. 2021;43:e2021044.   Published online July 13, 2021
DOI: https://doi.org/10.4178/epih.e2021044
  • 9,521 View
  • 275 Download
  • 1 Web of Science
  • 1 Crossref
AbstractAbstract AbstractSummary PDFSupplementary Material
Abstract
OBJECTIVES
Both cardiovascular health (CVH) and inflammation are associated with cognition, and inflammation is also associated with CVH. However, limited information has been reported on these factors in the Korean population. The objective of our study was to investigate the influence of inflammation on the association between CVH and cognition using a cross-sectional design.
METHODS
Data were obtained from the Cardiovascular and Metabolic Diseases Etiology Research Center baseline study. Participants who completed fasting serum analysis, questionnaires, and cognitive function tests were included in the analysis, whereas those with a history of autoimmune disease were excluded. The CVH in Ambulatory Care Research Team health index metrics, including smoking, physical activity, healthy diet, obesity, history of hypertension, and diabetes, were used to assess CVH. Cognitive function was evaluated with the Korean version of the Mini-Mental State Estimation for Dementia Screening. Inflammatory status was assessed based on a high-sensitivity C-reactive protein (hs-CRP) test.
RESULTS
Among 2,622 total participants (mean age, 57.2 years; 1,792 women), 13%, 58%, and 29% had poor, intermediate, and ideal CVH, respectively. Logistic regression analysis demonstrated that CVH was significantly associated with cognitive function only in women. A stratified analysis showed that cognitive impairment due to CVH was not associated with hs-CRP levels. When the same analyses were conducted for each CVH component, the only component affecting the association was hypertension history in men.
CONCLUSIONS
CVH is not significantly associated with cognitive decline in the middle-aged Korean population. Inflammation did not play a significant modifying role in this relationship.
Summary
Korean summary
• 본 연구는 심뇌혈관 및 대상질환원인연구센터(Cardiovascular and Metabolic Diseases Etiology Research Center, CMERC) 코호트의 기반조사 데이터를 활용하여, 심혈관계건강과 인지기능 사이의 연관성을 한국 도시거주 중년인구에서 확인하고, 염증 지표인 고감도C반응단백 (high-sensitivity C-reactive protein, hs-CRP) 수준에 따른 차이를 탐색하였다. • 남성과 여성 모두에서 CANHEART health index가 낮은 집단에서 인지기능이 평균적으로 더 낮았으나, 통계적으로 유의하지는 않았다. • 염증 수준에 따른 심혈관계건강과 인지기능 사이의 연관성은 해당 연구에서는 확인할 수 없었다.
Key Message
In the Korean middle-aged population, poor cardiovascular health (CVH) assessed by CANHEART health index was associated with low cognitive function, but not statistically significant. Further investigation is suggested to develop CVH index specified in Korean populations and to estimate the association between CVH and cognitive function in larger population.

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  • Cardiovascular disease risk models and dementia or cognitive decline: a systematic review
    Ruirui Jia, Qing Wang, Hengyi Huang, Yanli Yang, Yuet Foon Chung, Tao Liang
    Frontiers in Aging Neuroscience.2023;[Epub]     CrossRef
Predictors of anticipated coping behavior at myocardial infarction symptom onset among a nationwide sample of Korean adults
Kyong Sil Park
Epidemiol Health. 2021;43:e2021006.   Published online January 3, 2021
DOI: https://doi.org/10.4178/epih.e2021006
  • 11,172 View
  • 361 Download
  • 1 Web of Science
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AbstractAbstract AbstractSummary PDFSupplementary Material
Abstract
OBJECTIVES
This cross-sectional study based on the health belief model investigated predictors of anticipated coping behavior at myocardial infarction (MI) symptom onset using secondary data from the 2017 Korea Community Health Survey.
METHODS
Modifying variables (socioeconomic, health knowledge, perceived threat) were selected as independent variables and anticipated coping behavior at MI symptom onset as the dependent variable. Calling 911 was classified as the correct anticipated coping behavior, while visiting a hospital or an oriental hospital, calling family, and others were classified as incorrect.
RESULTS
Of 227,740 participants, 83.2% reported correct anticipated coping behaviors. The likelihood of calling 911 was low if participants experienced atypical symptoms (jaw, neck, back, arm, and shoulder pain), even if they were aware of those symptoms. However, 69.9% of participants who were aware of typical symptoms (chest pain) stated that they would call-911. Sex, age, hypertension, dyslipidemia, obesity, and awareness of MI symptoms affected the correct anticipated coping behavior.
CONCLUSIONS
Correct coping abilities among the general public are vitally important for early treatment of MI patients and reduction of hospitalization time. Members of the general public in their 20s and 30s, 60 years of age or older, with cardiovascular risk factors (male sex, hypertension, dyslipidemia, and obesity), and who are not aware of MI symptoms should be educated about the typical and atypical symptoms of MI. Emergency medical services should be called without delay if needed, and public relations activities should be carried out to raise awareness that anyone can use emergency medical services.
Summary
Korean summary
심근경색증 증상 발현 시 올바른 대처 행동을 위해 20-39세, 60세 이상, 남성, 고혈압, 이상지질혈증, 비만이 있는 대상자, 심근경색증 증상을 인지하지 못하는 대상자에게 심근경색증의 전형적, 비전형적 증상에 대해 교육해야 한다. 또한, 환자 발생 시 지체없이 응급의료서비스 신고해야하며, 누구나 응급의료서비스를 이용할 수 있도록 인식 전환을 위한 홍보활동을 시행해야 한다.
Key Message
Those in their 20s and 30s, 60 years of age or older, male, with cardiovascular risk factors, and who are not aware of MI symptoms should be educated about the typical and atypical symptoms of MI. Public relations activities should be carried out to raise awareness that anyone can use EMS.

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  • Application of intensive management of risk awareness combined with cardiac rehabilitation nursing in elderly patients with acute myocardial infarction and heart failure
    Xiaoli Yin, Cuiping Huang, Binglai Lin
    Medicine.2024; 103(20): e37381.     CrossRef
Associations of depression and anxiety with cardiovascular risk among people living with HIV/AIDS in Korea
Kyong Sil Park, Seon Young Hwang, Bo Youl Choi, June Kim, Sang Il Kim, Woo-Joo Kim, Chun Kang
Epidemiol Health. 2021;43:e2021002.   Published online December 24, 2020
DOI: https://doi.org/10.4178/epih.e2021002
  • 13,551 View
  • 388 Download
  • 2 Web of Science
  • 3 Crossref
AbstractAbstract AbstractSummary PDFSupplementary Material
Abstract
OBJECTIVES
As HIV/AIDS is becoming a chronic disease, the risk of developing cardiovascular disease (CVD) among people living with HIV/AIDS is rising. Anxiety and depression, which are common among people living with HIV/AIDS, have been linked with CVD. This study investigated the risk of CVD in people living with HIV/AIDS and explored the effects of depression and anxiety on CVD risk.
METHODS
Data were collected for 457 people enrolled in the Korea Cohort HIV/AIDS study after 2010. Framingham risk scores were calculated to quantify the 10-year risk of developing CVD. Depression and anxiety variables were re-coded as a single combined variable. Multivariable logistic regression analysis was performed, adjusting for age, body mass index, low-density lipoprotein (LDL) cholesterol, triglycerides (TG), duration of human immunodeficiency virus (HIV) positivity after entry into the cohort, and depression/anxiety.
RESULTS
Participants with both depression and anxiety were 2.28 times more likely than those with neither depression nor anxiety to have moderate/high-risk CVD risk. The 10-year risk of developing CVD was affected by LDL cholesterol, TG, age, and duration of HIV infection. LDL cholesterol and TG levels change according to the duration of HIV infection, and metabolic disorders affect the risk of CVD. Thus, a longer duration of HIV infection is associated with a higher risk of developing CVD.
CONCLUSIONS
Screenings for depression and anxiety need to be provided regularly to assess the severity of those symptoms. To help decrease their risk of developing CVD, people living with HIV/AIDS should be offered behavioral modification interventions aimed at developing healthy lifestyle habits.
Summary
Korean summary
본 연구를 통해 우울과 불안이 심혈관질환 발생위험을 증가시키는 영향요인임을 확인하였다. 따라서, HIV 감염자의 우울과 불안에 대한 정기적인 검사 및 상담이 필요하며, 우울 또는 불안한 환자의 심혈관질환의 발병 위험을 줄이기위해 좋은 생활 습관을 위한 행동 수정 및 동기 부여 교육프로그램의 개발이 필요하다.
Key Message
healthcare providers need to provide motivational education for behavioral modifications to decrease patients’ risk of developing CVD, especially among those with depression or anxiety symptoms.

Citations

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  • Comorbidities among persons living with HIV (PLWH) in Florida: a network analysis
    Shyfuddin Ahmed, Angel B. Algarin, Hsu Thadar, Zhi Zhou, Tanjila Taskin, Krishna Vaddiparti, Karina Villalba, Yan Wang, Nicole Ennis, Jamie P. Morano, Charurut Somboonwit, Robert L Cook, Gladys E. Ibañez
    AIDS Care.2023; 35(7): 1055.     CrossRef
  • Elevated frequency and everyday functioning implications of vascular depression in persons with HIV disease
    Ilex Beltran-Najera, Andrea Mustafa, Desmond Warren, Zach Salling, Maria Misiura, Steven Paul Woods, Vonetta M. Dotson
    Journal of Psychiatric Research.2023; 160: 78.     CrossRef
  • MENTE X CORAÇÃO: AS DOENÇAS PSIQUICAS E AS CONSENQUÊNCIAS CARDIOVASCULARES: UMA REVISÃO DA LITERATURA
    Beatriz da Silva Araújo, Morgana Gonçalves da Silva
    Revista interdisciplinar em saúde.2021; 8(Único): 292.     CrossRef
Renal hyperfiltration, fatty liver index, and the hazards of all-cause and cardiovascular mortality in Finnish men
Mounir Ould Setti, Ari Voutilainen, Tomi-Pekka Tuomainen
Epidemiol Health. 2021;43:e2021001.   Published online December 24, 2020
DOI: https://doi.org/10.4178/epih.e2021001
  • 12,460 View
  • 366 Download
  • 5 Web of Science
  • 4 Crossref
AbstractAbstract AbstractSummary PDFSupplementary Material
Abstract
OBJECTIVES
Renal hyperfiltration (RHF) and fatty liver are separately associated with adverse health outcomes. In this study, we investigated the mortality hazard of coexisting RHF and fatty liver.
METHODS
Middle-aged men from the Kuopio Ischaemic Disease Risk Factor Study (n=1,552) were followed up for a median of 29 years. Associations among RHF, fatty liver index (FLI) score, age, body mass index, smoking status, alcohol consumption, and hypertension status were assessed using logistic regression. Cox proportional hazards models were used to determine the hazard ratios (HRs) for all-cause and cardiovascular disease (CVD) mortality with respect to RHF and fatty liver.
RESULTS
Of the men, 5% had RHF (n=73), whereas a majority had fatty liver (n=848). RHF was associated specifically with smoking, and fatty liver was associated specifically with overweight. The all-cause mortality hazard was highest (HR, 1.96; 95% confidence interval [CI], 1.27 to 3.01) among men with RHF and fatty liver (n=33). Among men with RHF but normal FLI (n=40), the HR of all-cause mortality was 1.67 (95% CI, 1.15 to 2.42). Among men with fatty liver but a normal estimated glomerular filtration rate (n=527), the HR of all-cause mortality was 1.35 (95% CI, 1.09 to 1.66). CVD mortality hazard was associated with RHF, but not fatty liver. We detected no interaction effect between RHF and fatty liver for all-cause (synergy index, 0.74; 95% CI, 0.21 to 2.67) or CVD (synergy index, 0.94; 95% CI, 0.34 to 2.60) mortality.
CONCLUSIONS
RHF and fatty liver are independently associated with all-cause and CVD mortality
Summary
Key Message
Both prevalent, underdiagnosed, and commonly coexisting, renal hyperfiltration and fatty liver are two notable independent risk factors of all-cause and cardiovascular disease mortality.

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  • Impact of gout on cardiovascular disease mortality: a meta-analysis
    Jielin Yuan, Zhitao Xie, Bo Pan, Jingchang Zhang
    Zeitschrift für Rheumatologie.2024;[Epub]     CrossRef
  • Sex-specific association of body mass index and fatty liver index with prevalence of renal hyperfiltration: a cross sectional study using Japanese health check-up data
    Atsushi Kitazawa, Yoshiharu Fukuda
    BMC Nephrology.2023;[Epub]     CrossRef
  • Glomerular Hyperfiltration: A Marker of Fibrosis Severity in Metabolic Associated Steatotic Liver Disease in an Adult Population
    Andrea Dalbeni, Marta Garbin, Mirko Zoncapè, Sara Romeo, Filippo Cattazzo, Anna Mantovani, Annalisa Cespiati, Anna Ludovica Fracanzani, Emmanouil Tsochatzis, David Sacerdoti, Alessandro Mantovani, Rosa Lombardi
    International Journal of Molecular Sciences.2023; 24(21): 15837.     CrossRef
  • Fatty Liver Index Independently Predicts All-Cause Mortality in Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis but No Substantial Liver Disease
    Pil Gyu Park, Jung Yoon Pyo, Sung Soo Ahn, Hyun Joon Choi, Jason Jungsik Song, Yong-Beom Park, Ji Hye Huh, Sang-Won Lee
    Frontiers in Cardiovascular Medicine.2022;[Epub]     CrossRef
Modification of the effect of ambient air temperature on cardiovascular and respiratory mortality by air pollution in Ahvaz, Iran
Sohrab Iranpour, Soheila Khodakarim, Abbas Shahsavani, Ardeshir Khosravi, Koorosh Etemad
Epidemiol Health. 2020;42:e2020053.   Published online July 18, 2020
DOI: https://doi.org/10.4178/epih.e2020053
  • 11,078 View
  • 224 Download
  • 6 Web of Science
  • 2 Crossref
AbstractAbstract PDFSupplementary Material
Abstract
OBJECTIVES
This study investigated the modification of temperature effects on cardiovascular and respiratory mortality by air pollutants (particulate matter less than 2.5 and 10 µm in diameter [respectively], ozone, nitrogen dioxide, carbon monoxide, and sulfur dioxide).
METHODS
Poisson additive models with a penalized distributed lag non-linear model were used to assess the association of air temperature with the daily number of deaths from cardiovascular and respiratory diseases in Ahvaz, Iran from March 21, 2014 to March 20, 2018, controlling for day of the week, holidays, relative humidity, wind speed, air pollutants, and seasonal and long-term trends. Subgroup analyses were conducted to evaluate the effect modification for sex and age group. To assess the modification of air pollutants on temperature effects, the level of each pollutant was categorized as either greater than the median value or less than/equal to the median value.
RESULTS
We found no significant associations between temperature and cardiovascular and respiratory mortality. In the subgroup analyses, however, high temperatures were significantly associated with an increased risk of cardiovascular mortality among those 75 years old and older, with the strongest effect observed on day 0 relative to exposure. The results revealed a lack of interactive effects between temperature and air pollutants on cardiovascular and respiratory mortality.
CONCLUSIONS
A weak but significant association was found between high temperature and cardiovascular mortality, but only in elderly people. Air pollution did not significantly modify the effect of ambient temperature on cardiovascular and respiratory mortality.
Summary

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  • Associations between ambient temperature and suicide: а systematic review
    Andrej М. Grjibovski, Ivan М. Kobelev, Natalia N. Kukalevskaya, Yulia A. Popova, Alexander V. Baranov
    Ekologiya cheloveka (Human Ecology).2023; 30(6): 399.     CrossRef
  • Combined effects of air pollution and extreme heat events among ESKD patients within the Northeastern United States
    Richard V. Remigio, Hao He, Jochen G. Raimann, Peter Kotanko, Frank W. Maddux, Amy Rebecca Sapkota, Xin-Zhong Liang, Robin Puett, Xin He, Amir Sapkota
    Science of The Total Environment.2022; 812: 152481.     CrossRef
Brief Communication
Testosterone levels and cause-specific mortality in the older French men without metabolic syndrome
Nasser Laouali, Sylvie Brailly-Tabard, Catherine Helmer, Marie-Laure Ancelin, Christophe Tzourio, Alexis Elbaz, Anne Guiochon-Mantel, Marianne Canonico
Epidemiol Health. 2020;42:e2020036.   Published online June 1, 2020
DOI: https://doi.org/10.4178/epih.e2020036
  • 11,417 View
  • 132 Download
  • 1 Crossref
AbstractAbstract PDFSupplementary Material
Abstract
OBJECTIVES
Previous studies have reported controversial findings regarding the association of testosterone with mortality in older men. This heterogeneity might be partially explained by comorbidities and the presence of metabolic syndrome, as well as differential associations according to causes of death.
METHODS
We used data from a random subsample of the Three-City study, in which hormone levels were measured in 338 men ≥65 years without metabolic syndrome who were followed-up for 12 years. Vital status was determined for all participants from different sources. We used inverse-probability-weighted Cox regression to estimate the hazard ratios (HRs) of cause-specific mortality and 95% confidence intervals (CIs).
RESULTS
Over the follow-up period, 130 men died (30 from cardiovascular disease, 45 from cancer, 55 from other causes). The association of testosterone with mortality showed significant heterogeneity across causes of death (p=0.027 and p=0.022 for total and bioavailable testosterone, respectively). Higher testosterone levels were associated with increased cardiovascular mortality (HR for 1-standard deviation increase, 1.86; 95% CI, 1.28 to 2.71 and 1.50; 95% CI, 1.04 to 2.17 for total and bioavailable testosterone, respectively). By contrast, there were no significant associations of testosterone with mortality from cancer and other causes.
CONCLUSIONS
Our data suggest that the association of testosterone with mortality in men without metabolic syndrome might be differential according to the cause of death. These findings may partially explain the heterogeneity across studies on the relationship between testosterone levels and mortality.
Summary

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  • Testosterone, atherosclerosis and cardiovascular risks
    Anastasia V. Makarova, Sergey B. Shustov, Yuri S. Khalimov, Sergey V. Gaiduk, Viktor P. Kitsyshin, Dmitry S. Frolov
    Bulletin of the Russian Military Medical Academy.2023; 25(3): 481.     CrossRef
Original Article
Factors affecting awareness of myocardial infarction symptoms among the general public in Korea
Kyong Sil Park
Epidemiol Health. 2020;42:e2020032.   Published online May 18, 2020
DOI: https://doi.org/10.4178/epih.e2020032
  • 12,412 View
  • 234 Download
  • 12 Web of Science
  • 10 Crossref
AbstractAbstract AbstractSummary PDFSupplementary Material
Abstract
OBJECTIVES
We aimed to determine the level of awareness of myocardial infarction (MI) symptoms among the general public in Korea and identify factors affecting awareness of MI symptoms using data from the 2017 Korea Community Health Survey (KCHS).
METHODS
This is a cross-sectional study using KCHS data. Based on five questions about MI symptoms, participants were divided into an awareness group (replied ‘yes’ to all five questions) and an unawareness group (replied ‘no’ or ‘not sure’ to at least one of five questions) for analysis.
RESULTS
Of a total of 228,281 participants, 42.4% were aware of MI symptoms. There was a high level of awareness of chest pain and shortness of breath, but a low level of awareness of gastrointestinal symptoms and pain in the arm, shoulder, jaw, neck, and back. While women had a higher level of overall awareness relative to men, they showed a lower level of awareness regarding chest pain and discomfort. The factors affecting awareness of MI symptoms were gender, age, education level, occupation, smoking, drinking, physical inactivity, and cardiovascular disease risk factors.
CONCLUSIONS
In order to enhance awareness of MI symptoms among the general population, appropriate education and promotion efforts must be implemented based on gender, age, education level, and occupation. Moreover, active efforts by the government, educational institutions, and medical institutions are necessary to improve awareness of both typical and atypical MI symptoms. Furthermore, health policies to promote reduced smoking and drinking and increased physical activity, as well as continuous monitoring and management of individuals with cardiovascular disease risk factors, are required.
Summary
Korean summary
2017년 지역사회건강조사 자료를 분석한 결과, 한국의 심근경색증 증상의 인지율은 42%로 낮은 인식을 보였다. 한국의 지역사회 내 일반인들의 심근경색증 증상의 인지율을 제고하기 위해 성별, 연령, 교육수준, 직업을 고려하여 교육 및 홍보를 실시해야 한다. 그리고, 전형적인 심근경색증 증상뿐만 아니라 비전형적인 심근경색증 증상에 대한 인식에 대한 정부, 교육기관, 의료기관 등의 적극적인 노력이 필요하다. 또한, 금연, 금주, 신체활동 증진에 대한 보건정책적 관리방안과 심혈관질환 위험요인을 가진 대상자들의 지속적인 모니터링 및 관리가 필요하다.

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  • Recognition of Early Cardiovascular Disease Symptoms in Hypertensive and Dyslipidemic Individuals of Icheon, Korea: Insights into Educational Levels and Health Literacy
    Jeehye Lee, Dong-Hee Ryu
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  • Engaging social activities prevent stroke and myocardial infraction by raising awareness of warning symptoms: A cross-sectional survey study
    Gahyeon Kim, Hyeokjoo Jang, Sebin Kwon, Bumyeol Lee, Suk-Yong Jang, Wonjeong Chae, Sung-In Jang
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  • “Recognition of heart attack symptoms and treatment-seeking behaviors: a multi-center survey in Tehran, Iran”
    Elnaz Shahmohamadi, Mojtaba Sedaghat, Arash Rahmani, Farnoosh Larti, Babak Geraiely
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  • Identifying and Solving Gaps in Pre- and In-Hospital Acute Myocardial Infarction Care in Asia-Pacific Countries
    Paul Jie Wen Tern, Amar Vaswani, Khung Keong Yeo
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  • Awareness of Myocardial Infarction Symptoms and Risk Factors in Saudi Arabia: A Cross-Sectional Study
    Saad M Alsaab, Ahmed M Almutairi, Ghadi K Alsaadi, Ziyad A Altokhais, Samar H Alabdulqader, Wafa Y Alnofal, Nourah M Alduhaim
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  • Gender and Social Inequalities in Awareness of Coronary Artery Disease in European Countries
    Antonio Daponte-Codina, Emily C. Knox, Inmaculada Mateo-Rodriguez, Amanda Seims, Vera Regitz-Zagrosek, Angela H. E. M. Maas, Alan White, Floris Barnhoorn, Fernando Rosell-Ortiz
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    Yeo Won Jeong
    Healthcare.2021; 9(3): 360.     CrossRef
  • Global Awareness of Myocardial Infarction Symptoms in General Population: a Systematic Review and Meta-Analysis
    Akash Sharma, Karavadi Vidusha, Harshini Suresh, Ajan M. J., Kavinkumar Saravanan, Madhvi Dhamania, Nisha B, Rabbanie Tariq Wani
    Korean Circulation Journal.2021; 51(12): 983.     CrossRef
  • Global Awareness of Myocardial Infarction Symptoms in General Population
    Soo-Joong Kim
    Korean Circulation Journal.2021; 51(12): 997.     CrossRef
  • Disparities in Awareness of Myocardial Infarction and Stroke Symptoms and Response Among United States– and Foreign‐Born Adults in the National Health Interview Survey
    Ivy Mannoh, Ruth‐Alma Turkson‐Ocran, Jasmine Mensah, Danielle Mensah, Stella S. Yi, Erin D. Michos, Yvonne Commodore‐Mensah
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Epidemiol Health : Epidemiology and Health