Epidemiology and Health

Original Articles

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

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Abstract Summary PDF Supplementary 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.

Impaired pulmonary function mediates the impact of preterm birth on later-life stroke: a 2-step, multivariable Mendelian randomization study: Xingzhi Guo, Peng Tang, Chen Hou, Yue Liu, Rui Li; Epidemiol Health. 2023;45:e2023031. Published online March 3, 2023; DOI: https://doi.org/10.4178/epih.e2023031

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Abstract

OBJECTIVES
Observational studies have suggested an association between preterm birth and stroke in late adulthood, but it remains unclear whether the association is causal. The purpose of this study was to evaluate the causal effects of gestational age on stroke and to determine the pathophysiological mechanisms underlying the causal associations.

METHODS

Two-sample Mendelian randomization (MR) was performed to assess the causal effects of fetal gestational duration, early preterm birth (EPB), preterm birth, or postterm birth on stroke and its subtypes. Two-step Mendelian randomization (TSMR) and multivariable Mendelian randomization (MVMR) were additionally used to determine the role of common stroke risk factors, including cardiovascular diseases, hypertension, pulmonary impairment, inflammation, and metabolic diseases, in mediating the causal associations between gestational age and stroke and its subtypes.

RESULTS

Genetically predicted EPB increased the risk of cardioembolic stroke (CES; odds ratio [OR], 1.115; 95% confidence interval [CI], 1.036 to 1.200; p=0.004) and large artery stroke (LAS; OR, 1.131; 95% CI, 1.031 to 1.241; p=0.009). The TSMR results showed that EPB was associated with a lower forced expiratory volume in the first second and forced vital capacity ratio (FEV1/FVC) (β=-0.020; 95% CI, -0.035 to -0.005; p=0.009), which increased the risk of CES and LAS. Further MVMR analysis showed that the associations between EPB and stroke disappeared after adjustment for FEV1/FVC.

CONCLUSIONS

Our data demonstrate that EPB is causally associated with an elevated risk of CES and LAS, and that pulmonary dysfunction mediates the causal impact of EPB on CES and LAS.

Summary

Key Message
Genetically predicted early preterm birth (EPB) is significantly associated with an increased risk of cardioembolic stroke (CES) and large artery stroke (LAS). Further multivariable Mendelian randomization analysis demonstrates that pulmonary impairment mediates the causal impact of EPB on CES and LAS in adulthood.

Citations

Citations to this article as recorded by

Causal associations of circulating Helicobacter pylori antibodies with stroke and the mediating role of inflammation
Xingzhi Guo, Peng Tang, Xin Zhang, Rui Li
Inflammation Research.2023; 72(6): 1193. CrossRef

The risk of stroke according to statin medication compliance in older people with chronic periodontitis: an analysis using the Korea National Health Insurance Service-Senior Cohort Database: Seon-Rye Kim, Minkook Son, Yu-Rin Kim; Epidemiol Health. 2022;44:e2022055. Published online July 5, 2022; DOI: https://doi.org/10.4178/epih.e2022055

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
We investigated the risk of stroke according to statin medication compliance in older people with chronic periodontitis.
METHODS
Chronic periodontitis patients were extracted from the National Health Insurance Service-Senior Cohort Database from 2002 to 2014. Among 255,056 chronic periodontitis patients, 41,412 patients with statin prescriptions for 28 days or more were included. The study population was divided into the top 25% of medication compliance group (TSG) and the lower 25% of medication compliance group (BSG). After 1:1 propensity score matching was performed, the final number of patients in the BSG and TSG was 6,172 each. To analyze the risk of stroke, a Cox proportional hazard model was performed to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs) after adjusting for age, sex, income level, hypertension, diabetes, and Charlson comorbidity index.
RESULTS
In the Kaplan-Meier curve, the disease-free probability was prominently lower in the BSG than in the TSG (p for log-rank= 0.001). The HR in the multivariable-adjusted model for stroke occurrence in the TSG compared to the BSG was 0.79 (95% CI, 0.67 to 0.92; p= 0.002). Subgroup analyses showed significant associations between compliance to statin medication and stroke, especially in female, people 85 years or older, and patients with comorbidities.
CONCLUSIONS
Increasing compliance to statins may reduce stroke risk in older adults with chronic periodontitis. Therefore, in order to increase medication compliance among older people with chronic periodontitis, it is necessary for medical staff to make efforts to provide effective medication guidance.; Summary

Korean summary
만성치주질환을 가진 노인에서 스타틴 복용순응도가 낮은 그룹에 비해 높은 그룹이 뇌졸증 발생위험이 낮았다. 특히 여성과 후기 노인 (85세 이상), 동반 질환을 가진 그룹에서 유의한 차이가 있었다. 따라서 스타틴 복용 순응도를 증대시키기 위한 의료진의 노력이 필요할 것이다.

Key Message
The stroke risk of chronic periodontal disease patients was related to statin medication compliance, and the effect of stroke risk was different in women, the elderly, and comorbidities.

Associations between dietary risk factors and ischemic stroke: a comparison of regression methods using data from the Multi-Ethnic Study of Atherosclerosis: Seyed Saeed Hashemi Nazari, Yaser Mokhayeri, Mohammad Ali Mansournia, Soheila Khodakarim, Hamid Soori; Epidemiol Health. 2018;40:e2018021. Published online May 21, 2018; DOI: https://doi.org/10.4178/epih.e2018021

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7 Citations

Abstract PDF

Abstract

OBJECTIVES
We analyzed dietary patterns using reduced rank regression (RRR), and assessed how well the scores extracted by RRR predicted stroke in comparison to the scores produced by partial least squares and principal component regression models.

METHODS

Dietary data at baseline were used to extract dietary patterns using the 3 methods, along with 4 response variables: body mass index, fibrinogen, interleukin-6, and low-density lipoprotein cholesterol. The analyses were based on 5,468 males and females aged 45-84 years who had no clinical cardiovascular disease, using data from the Multi-Ethnic Study of Atherosclerosis.

RESULTS

The primary factor derived by RRR was positively associated with stroke incidence in both models. The first model was adjusted for sex and race and the second model was adjusted for the variables in model 1 as well as smoking, physical activity, family and sibling history of stroke, the use of any lipid-lowering medication, the use of any anti-hypertensive medication, hypertension, and history of myocardial infarction (model 1: hazard ratio [HR], 7.49; 95% confidence interval [CI], 1.66 to 33.69; p for trend=0.01; model 2: HR, 6.83; 95% CI, 1.51 to 30.87 for quintile 5 compared with the reference category; p for trend=0.02).

CONCLUSIONS

Based primarily on RRR, we identified that a dietary pattern high in fats and oils, poultry, non-diet soda, processed meat, tomatoes, legumes, chicken, tuna and egg salad, and fried potatoes and low in dark-yellow and cruciferous vegetables may increase the incidence of ischemic stroke.

Summary

Citations

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Comparison of data-driven identified hypertension-protective dietary patterns among Chinese adults: based on a nationwide study
Yuxiang Yang, Wei Piao, Shuya Cai, Kun Huang, Changzheng Yuan, Xue Cheng, Ling Zhang, Yuge Li, Liyun Zhao, Dongmei Yu
European Journal of Nutrition.2023; 62(7): 2805. CrossRef
Associations between dietary patterns and cardiovascular disease risk in Canadian adults: a comparison of partial least squares, reduced rank regression, and the simplified dietary pattern technique
Svilena V Lazarova, Mahsa Jessri
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Mahsa Samadani, Anahita Mansoori, Habib Haybar, Fatemeh Haidari, Majid Mohammadshahi
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Visceral adiposity-related dietary patterns and the risk of cardiovascular disease in Iranian adults: A population-based cohort study
Nazanin Moslehi, Fatemeh Rahimi Sakak, Maryam Mahdavi, Parvin Mirmiran, Fereidoun Azizi
Frontiers in Nutrition.2022;[Epub] CrossRef
Dietary patterns derived by reduced rank regression and non-communicable disease risk
Carmen Piernas, Min Gao, Susan A. Jebb
Proceedings of the Nutrition Society.2022; : 1. CrossRef
Dietary patterns related to cardiovascular disease based on reduced rank regression analysis of healthy middle-aged Koreans: data from the community-based Korean Genome and Epidemiology Study (KoGES) cohort
Hye Ah Lee, Hyoin An, EunJin Lee
The American Journal of Clinical Nutrition.2020; 111(6): 1159. CrossRef
Interaction between an ATP-Binding Cassette A1 (ABCA1) Variant and Egg Consumption for the Risk of Ischemic Stroke and Carotid Atherosclerosis: a Family-Based Study in the Chinese Population
Jing Song, Xia Jiang, Yaying Cao, Juan Juan, Tao Wu, Yonghua Hu
Journal of Atherosclerosis and Thrombosis.2019; 26(9): 835. CrossRef

Review

Registry-based stroke research in Taiwan: past and future: Cheng-Yang Hsieh, Darren Philbert Wu, Sheng-Feng Sung; Epidemiol Health. 2018;40:e2018004. Published online February 4, 2018; DOI: https://doi.org/10.4178/epih.e2018004

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15 Citations

Abstract PDF

Abstract

Stroke registries are observational databases focusing on the clinical information and outcomes of stroke patients. They play an important role in the cycle of quality improvement. Registry data are collected from real-world experiences of stroke care and are suitable for measuring quality of care. By exposing inadequacies in performance measures of stroke care, research from stroke registries has changed how we manage stroke patients in Taiwan. With the success of various quality improvement campaigns, mortality from stroke and recurrence of stroke have decreased in the past decade. After the implementation of a nationwide stroke registry, researchers have been creatively expanding how they use and collect registry data for research. Through the use of the nationwide stroke registry as a common data model, researchers from many hospitals have built their own stroke registries with extended data elements to meet the needs of research. In collaboration with information technology professionals, stroke registry systems have changed from web-based, manual submission systems to automated fill-in systems in some hospitals. Furthermore, record linkage between stroke registries and administrative claims databases or other existing databases has widened the utility of registry data in research. Using stroke registry data as the reference standard, researchers have validated several algorithms for ascertaining the diagnosis of stroke and its risk factors from claims data, and have also developed a claims-based index to estimate stroke severity. By making better use of registry data, we believe that we will provide better care to patients with stroke.

Summary

Citations

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STAIR X
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Original Article

Evaluation of risk prediction model for stroke risk based on Cox's and Weibull model in Korea.: Youn Nam Kim, Ur Rin Cho, Byung Ho Nam, Il Soo Park, Sun Ha Jee; Korean J Epidemiol. 2008;30(1):41-48. Published online June 30, 2008; DOI: https://doi.org/10.4178/kje.2008.30.1.41

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Abstract PDF: Abstract
OBJECTIVE: The objective was to compare Cox proportional hazards model and Weibull model for predicting long-term probabilities for stroke risk in the Korean Cancer Prevention Study(KCPS).
METHODS
The subjects comprised of 385,279 Korean aged 55 to 64 years who received health insurance from the National Health Insurance Corporation and who had medical examinations in 1992 and 1995. 70% of the subjects were used for model building and the rest for model evaluation. The final prediction model for stroke includes age, systolic blood pressure, diabetes, total cholesterol and smoking. Subjects were follow-up for identification of incident stroke cases between 1993 and 2005. Comparisons included predicted coefficients of stroke risk factors, incidence probabilities over 10 years, and the area under a receiver operating characteristics (ROC) curve for both Cox's proportional hazard model and Weibull model.
RESULTS
The average age of study population was 55.5 years in men and 56.3 years in women, respectively. Percentage of men and women in study population were 58.0% and 42.0%, respectively. The study findings satisfied proportionality according to the two models. There was no significant difference in coefficients between the two models of prediction models in men and in women. Moreover, there was no difference in incidence probabilities of stroke and c-statistics. C-statistics were 0.68 for men as same as for women.
CONCLUSION
There was no difference for the prediction of the stroke risk in the Korean population using Cox's proportional hazard model and Weibull model, thus the two models were found to be efficient for this purpose.; Summary

Review

Studies on the Association between Phenylpropanolamine (PPA) and Hemorrhagic Stroke in Other Countries.: Seung Mi Lee, Byung Woo Yoon, Byung Joo Park; Korean J Epidemiol. 2004;26(2):1-7.

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Abstract PDF: Abstract
OBJECTIVES
Phenylpropanolamine (PPA) had been used widely as cold remedies or appetite suppressants. However, products containing PPA were withdrawn in sequence in the US, Japan, and Korea due to the increased risk of hemorrhagic stroke. The purpose of this paper was to review safety issues related with the PPA use and hemorrhagic stroke in view of pharmacoepidemiology and pharmacovigilance.
METHODS
AND MATERIALS: Researches conducted for evaluating the association between the PPA use and hemorrhagic stroke in other countries were reviewed, which involved case reports, case series, case-control studies, and cohort studies.
RESULTS
In terms of pharmacologic and clinical features, PPA may increase the risk of hemorrhagic stroke through increased blood pressure, heart rate, or vasculitis. The association between the PPA use and hemorrhagic stroke among young women was suggested by case reports from spontaneous adverse events reporting systems or medical journals. The cohort study, using the large prescription database in the US and published in 1984, failed to reveal the association in the population aged below 65. The case-control study conducted as the Yale Hemorrhagic Stroke Project, published in 2000, was the first study to find the association between the PPA as appetite suppressants and hemorrhagic stroke among women ages 18-49 years by well-designed analytic epidemiological research. It led to withdrawal of all products containing PPA in the US and many other countries since 2000. However, the association between PPA and cerebral hemorrhage could not be confirmed by the case-control study conducted in Mexico due to inappropriate recruitment of control group.
CONCLUSIONS
During several years case reports have suggested that hemorrhagic stroke could be induced by PPA, and the Yale Hemorrhagic Stroke Project revealed the association by case-control study and provided a useful model for pharmacovigilance. Nevertheless, their finding could not be applied to other population such as elderly women and male population. And they could not provide any evidence on the association between PPA and stroke when PPA was used as cold remedy taken daily dose below 100mg.; Summary

Original Articles

Prevalence of Stroke in Pyongchang County.: Jong Ku Park, Kyung Sook Cho, Chun Bae Kim, Jin Back Kim, Ha Ja Song, Kee Ho Park, Seong Gyu Ko; Korean J Epidemiol. 2001;23(1):69-79.

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Abstract PDF: Abstract
PURPOSE
The purpose of this study was to identify the prevalence of stroke in Pyongchang county, Kangwon do.
METHODS
The presumptive stroke patients of Pyongchang county were identified with a key-person method in October 2000. And then, medical records of these patients were reviewed by well-trained two students who major in the science of medical record.
RESULTS
In the year 2000, there were 92 males and 68 females of self-diagnosed stroke. Of these, stroke patients based on physician's diagnosis were 102, and stroke patients based on CT/MRI findings or Minnesota criteria were 93. Prevalence rate of self-reported stroke, stroke based on physician's diagnosis, and stroke based on CT/MRI findings or Minnesota criteria were 0.33%, 0.29%, and 0.26% respectively.
CONCLUSION
We conclude that verifying process of diagnosis is needed to estimate the prevalence of stroke in community.; Summary

The Relationship Between Cholesterol Level and Mortality in Korean Women.: Yun Mi Song, Joo Hon Sung, Jai Jun Byeon, Joung Soon Kim, Oh Young Park; Korean J Epidemiol. 1997;19(2):131-146.

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Abstract PDF: Abstract
BACKGROUND
There were many efforts to evaluate the relationship between cholesterol and mortality. But almost all of them have been performed on male western people who have higher mean cholesterol concentration than oriental people and have different disease pattern from women's. So, upto now, the relationship of cholesterol to mortality in women with low cholesterol concentration was not well known. We carried out this study to investigate the relationship in Korea women whose mean cholesterol level was lower than that of western people and men.
METHOD
Study subjects included in were 100,363 Korean women aged 30-65 years. They undertook multiphasic health examination provided by Korea Medical Insurance Corporation between March 1990 and July 1990, and had no history of cancer and no significant medical illnesses which could change blood cholesterol level. Study subjects were followed for 5.5 years until December 1995 and it was determined whether each subject was dead or alive using the mortality data from the Korea National Statistical office and the Korea Medical Insurance Corporation. Nonlinear ralationship between serum total cholesterol and mortality was investigated with the use of quadratic regression and with dummy variables using the 158-180mg/dl group as the comparison group. To analyzing the relationship between cholesterol concentra-tion and mortality with controlling for age, smoking, alcohol drinking, exercise, diastolic blood pressure, body mass index, pay level, Cox propor-tional hazard model was used.
RESULT
During the follow-up period, there were 369 deaths. Mean cholesterol concentration of study subjects was 182.8mg/dl There was no significant association between serum cholesterol and total mortality, but women with cholesterol concentrations below 130mg/dl showed slightly increased risk of death(RR=1.20). Cholesterol had an inverse relationship with mortality from stroke, and women with cholesterol concentrations below 130mg/dl had higher risk of death from stroke(RR=3.28). Although there was no statistical significance,risk of mortality from hemorrhagic stroke in women with very low cholesterol concentration was markedly higher than in women with cholesterol concentrations above 130mg/dl. Mortality relationship with cholesterol. And women with cholesterol concentrations higher than 203mg/dl had abruply increased risk for death from ischemic heart disease.
CONCLUSION
Through this study, we could observe an inverse J shaped relationship between cholesterol concentration and mortality in Korean women. The increased risk of mortality from hemorrhagic stroke in people with very low cholesterol concentration supports the previous report which proposed low cholesterol level as a significant risk factor of hemorrhagic stroke. In spite of the lack of statistical signi-ficance, greately increased risk of mortality from ischemic heart disease in people with cholesterol higher than 203mg/dl suggests that cholesterol concentration at the upper end of distribution can be a significant risk factor of ischemic heart disease in women.; Summary

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