Heart failure (HF) is increasing throughout the developed world as a consequence of better survival rates following acute myocardial infarction (MI). South Asian (SA) patients with HF risk poorer outcomes through differing pathophysiological genesis, and a number of cultural and healthcare organisational factors. Nurses have a key role to play in attempting to reduce this potential disease burden among SA HF patients. This article discusses specific nursing care of the SA patient from the perspectives of diagnosis, aftercare, cultural and organisational barriers and tenders suggestions for improving service uptake among members of this marginalised group.

The elevated burden of cardiovascular disease (CVD) amongst South Asian populations is a complex and multi-factorial phenomenon. South Asians evolved from environments where malaria was endemic, and while haemoglobin disorders frequent this group, a link to CVD has not been described. Using a case -control feasibility study, haemoglobin abnormalities identified by mass spectrometry were compared between South Asian patients with CVD (n = 72) and non-CVD controls (n 84). Carotid-artery intima media thickness (CIMT) was used as a marker of vascular damage. Ultracentrifugation was used to separate lipoprotein subfractions, which were analysed for iron.Haemoglobin anomalies were more frequent for CVD patients than controls (34.7% vs. 14.3%, P < 0.001), as were subfractionated lipoprotein concentrations of iron (P < 0.001). Patients with haemoglobin disorders had greater CIMT (0.75 vs. 0.65 mm, P = 0.008), and lower HDL cholesterol (0.78 vs. 1.03 mmol/l, P = 0.003). These preliminary data suggest that haemoglobin disorders contribute to atherosclerotic disease in South Asians and further research is warranted. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

Within the United Kingdom, mortality from stroke is higher among South Asians compared to European whites. The reasons for this excess cerebrovascular risk in South Asians remain unclear. The aim of this review is to present a comprehensive and systematic overview of the available literature relating to ischemic stroke among South Asian populations identifying distinct features of stroke epidemiology in this group. Summary of Review— A high frequency of lacunar strokes is a familiar pattern among South Asians, which suggests a greater prevalence of small-vessel disease in South Asians. This may be a consequence of abnormal metabolic and glycemic processes. In addition, stroke mortality among South Asians appears to be explained by glycemic status, which is an independent predictor of long-term stroke mortality. Within India, there is a perceptible rural–urban gradient in stroke prevalence, underlying the dangers of the rapid transition in socioeconomic circumstances seen across the Indian subcontinent. Conclusions— This review emphasizes the importance of further research into ischemic stroke for South Asians given their higher cardiovascular disease burden and necessity for targeted healthcare approaches.

Background— The pathophysiology of an increased risk of cerebrovascular disease mortality among South Asians (SA) remains unclear. Indices of arterial stiffness and endothelial dysfunction are independent markers of vascular disease, having both prognostic and diagnostic implications. We hypothesized that there are ethnic variations in indices of arterial stiffness and endothelial dysfunction between SA and European Caucasian (EC) stroke patients, which may underline a poorer prognosis in the former, and further investigated promoters of vessel wall abnormalities. Methods— Using a cross-sectional approach, a total of 100 SA stroke survivors were prospectively recruited from the ongoing West Birmingham Stroke Project. Indices of vessel wall characteristics (arterial stiffness and endothelial function [change in reflective index]) were measured noninvasively using the digital volume pulse analysis technique in a temperature-controlled environment, using a direct standardized approach. SA stroke subjects were compared to 60 EC stroke survivors, 60 SA with risk factors, and 73 healthy controls. Results— Among stroke patients, both ethnic groups were comparable for cardiovascular risk profile, except for more diabetes mellitus in SA ( P =0.007) subjects and a higher prevalence of atrial fibrillation in EC ( P =0.04) subjects. According to the TOAST and Bamford classifications, SA subjects had more small vessel ( P =0.04) and lacunar infarctions ( P =0.01). SA subjects had higher measurements of arterial stiffness ( P <0.001) and impaired endothelial-dependent vascular function (change in reflective index %; P <0.001). On univariate analysis, endothelial function was negatively correlated with fasting plasma glucose ( r =−0.4; P <0.001) and total cholesterol level ( r =−0.2; P <0.001). On multivariate analysis, glycemic status was independently associated with impaired endothelial function ( P =0.008) and increased arterial stiffness ( P <0.001) among SA subjects. Conclusion— SA stroke survivors had more small vessel disease-related cerebrovascular events compared to EC subjects. Underlying glycemic status in SA subjects had an adverse impact on the vascular system, leading to abnormal vessel wall characteristics.

HomeStrokeVol. 40, No. 10Response to Letter by De Silva et al Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse to Letter by De Silva et al Ashan Gunarathne, MRCP Jeetesh V. Patel, PhD and Brian Gammon, PhD Paramjit S. Gill, FRCGP Elizabeth A. Hughes, FRCP and Gregory Y.H. Lip, MD Ashan GunarathneAshan Gunarathne City Hospital, Birmingham, UK Jeetesh V. PatelJeetesh V. Patel Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK and Brian GammonBrian Gammon Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK Paramjit S. GillParamjit S. Gill University of Birmingham, Birmingham, UK Elizabeth A. HughesElizabeth A. Hughes Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK and Gregory Y.H. LipGregory Y.H. Lip Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK Originally published10 Sep 2009https://doi.org/10.1161/STROKEAHA.109.560102Stroke. 2009;40:e595Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 10, 2009: Previous Version 1 Response:We are thankful for the helpful comments from De Silva and colleagues with respect to our review on "Ischemic Stroke in South Asians" published in Stroke (2009;40:e415–e423).In Table 1, with reference to De Silva et al,1 we commented that South Asian patients with stroke had a higher prevalence of hypertension and extracranial disease compared with Chinese patients with stroke. We accept that this was an incorrect comment and clearly not the case. Furthermore, with hindsight, the potential of such ethnic differences would not explain an increased stroke risk in South Asians because data would need to relate to cause preceding effect. Similarly, we were inaccurate to suggest a higher prevalence of lacunar strokes and small artery disease in South Asians given that it has been shown elsewhere that large artery stroke is common among South Asians.2,3,4 Nonetheless, our observation of a higher prevalence of lacunar strokes is confounded by the high prevalence of diabetes in South Asian populations.The comments by De Silva et al underline the complexity and limitations of characterizing cerebrovascular disease within populations.DisclosuresNone.1 De Silva DA, Woon FP, Lee MP, Fook-Chong S, Chang HM, Wong MC. Ischemic cerebrovascular disease: differences between ethnic South Asian and ethnic Chinese patient. Cerebrovasc Dis. 2005; 20: 407–409.CrossrefMedlineGoogle Scholar2 De Silva DA, Woon FP, Lee MP, Chen C, Chang HM, Wong MC. South Asian patients with ischemic stroke: intracranial large arteries are the predominant site of disease. Stroke. 2007; 38: 2592–2594.LinkGoogle Scholar3 Kaul S, Sunitha P, Suvarna A, Meena AK, Uma M, Reddy JM. Subtypes of ischemic stroke in a metropolitan city of South India. Neurol India. 2002; 50: S8–S14.Google Scholar4 De Silva DA, Woon FP, Lee MP, Chen CPLH, Chang HM, Wong MC. Intracranial large artery disease among OCSP subtypes in ethnic South Asian ischemic stroke patients. J Neurol Sci. 2007; 260: 147–149.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails October 2009Vol 40, Issue 10 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.109.560102 Originally publishedSeptember 10, 2009 Keywordsstroke carediabetesSouth Asiansepidemiologylacunar strokePDF download Advertisement

The pathophysiology of excessive premature cerebrovascular disease mortality amongst South Asian stroke survivors (SA) living in Britain remains unclear. We hypothesised that South Asian stroke survivors with underline impaired endothelial function have increased indices of higher arterial stiffness compared to their European Caucasian (EC) counterparts and these structural and functional vessel wall abnormalities and would account for their excess disease burden Endothelial dependent vessel dysfunction (RI) (post Salbutamol), independent (post Glyceryl Tri Nitrate) administration and arterial stiffness (SI) was measured by digital volume pulse photoplethysmography in 60 South Asian stroke survivors and compared to 60 age-gender matched European Caucasians in a temperature controlled environment using a direct, standardised approach. Both ethnic groups were comparable for CHD risk profiles , except diabetes mellitus (SA: 54.1

Background: Stroke is a major cause of premature mortality in Britain, but its burden is markedly greater amongst South Asians. Because of the paucity of data in this area, we investigated the magnitude and impact of risk from cardiovascular comorbidities on survival amongst South Asian stroke patients. Methods: We reviewed hospital case records of consecutive first in life time ischaemic stroke patients [self reported ethnicity and International Classification of Disease (ICD) 10th revision, codes 430-438] admitted to an inner city hospital in the UK between 1997 and 2001. In-hospital mortality data and CVD risk factors were analysed. Five-year mortality data was obtained from the National Health Tracing Services. Results: Of 1474 ischaemic stroke patients, 242 (16%) were South Asian of whom, 143 (59.1%) were male. The prevalence of hypertension was 70.2%, followed by diabetes 56.2%, hyperlipidaemia 7% and myocardial infarction 10.3%. At 5 years follow-up, 40.5% had died. Cumulative event-free survival at 5 years was significantly poorer in patients with diabetes (log-rank test, p = 0.009). On Cox regression analysis, incorporating age, gender and other CVD risk factors, diabetes mellitus was an independent predictor of mortality odds ratio = 1.65 (1.02-2.6, p = 0.039). Hypertension and dyslipidaemia did not discriminate survival amongst South Asian patients. Conclusion: Stroke mortality in South Asians is associated with presence of diabetes mellitus. This highlights the significance of early and intensive CVD risk modification strategies in ethnic minorities particularly in patients with diabetes. Further research is warranted in South Asians to examine the underlying basis and related pathophysiological abnormalities.

Despite a policy of inclusiveness in health care, the United Kingdom has made little progress in improving overall health among marginalised groups.1 There is a pressing need for clinical studies among South Asian, black, and other ethnic minority groups to aid the development of targeted strategies to prevent cardiovascular disease. A 1991 study, for example, showed that South Asians—then 4% of the total UK population—bore a disproportionately high burden of mortality from coronary heart disease and stroke.2 Health issues associated with the ageing of Britain’s ethnic minority population mean that new policy initiatives are urgently needed. Despite this urgency, however, this group is very rarely the focus of clinical investigations to prevent the adverse consequences of this disease burden. The reasons often given for South Asians’ lack of access to clinical trials include language difficulties, poorer access to health care, deprivation, alleged institutional discrimination, and a lack of cross cultural understanding and cultural competence.3 The South Asian population in the West Midlands, for …

BACKGROUND:The pathophysiology of excessive premature coronary heart disease mortality among South Asians living in Britain remains unclear. We hypothesized that higher measures of arterial stiffness among South Asians compared with their white European counterparts would reflect an earlier progression of atherosclerosis, even in the absence of established coronary heart disease risk indices. METHODS:Arterial stiffness was measured by digital volume pulse photoplethysmography in 90 healthy South Asians and compared with 62 matched white Europeans in a temperature-controlled environment using a direct, standardized approach. RESULTS:Both ethnic groups were comparable for coronary heart disease risk profiles and had similar 10-year coronary heart disease risk estimates, but South Asians had a greater mean (SD) stiffness index compared with white Europeans [9.39 (0.22) vs. 8.43 (0.23) m/s; P = 0.007]. On linear regression analysis, mean arterial blood pressure (beta = 0.06; P = 0.03) and age (beta = 0.11; P = 0.002) were independent predictors of arterial stiffness in South Asians. Among white Europeans, age was an independent predictor of arterial stiffness (beta = 0.05; P = 0.01). CONCLUSION:Healthy South Asians have increased systemic arterial stiffness measured by stiffness index compared with white Europeans. There was an adverse and disproportional impact of age and mean arterial pressure on the vascular system in South Asians. Increased indices of arterial stiffness may explain their increased susceptibility to coronary heart disease.

The assessment of endothelial function has been accepted as an independent surrogate marker of cardiovascular disease (CVD), having both positive prognostic and diagnostic implications. The Digital Volume Pulse (DVP) analysis technique is a non–invasive approach to derive endothelial function. However, the utility and clinical application of this analysis technique has not been established. we determined the discriminatory performance of the DVP analysis technique in identifying the people with established risk indices compared to a healthy population (West Midlands of the UK). Endothelial dependent and independent vessel function (Δ RI) was calculated by analyzing the change in digital pulse wave forms obtained by DVP photo-plethysmography technique(Micro Medicals) Of our cohort of (n=225) (60.1

Background The pathophysiology of increased coronary heart disease (CHD) risk affecting South Asians(SA) living in Britain remains unclear. For a given blood pressure SA have a higher risk of CHD than the indigenous European Caucasian(EC).We hypothesised that measures of arterial stiffness would be greater amongst healthy SA compared to EC counterparts specifically ,in the absence of raised blood pressure and established CHD risk indices. Methods Arterial stiffness was measured by digital volume pulse photo-plethysmography (Micromedicals PCA 2) in 90 healthy SA (and compared to age-gender matched 62 EC in a temperature controlled environment using a standard protocol. Results SA and EC’s were comparable for CVD risk profile (Table 1). South Asians had an increased Stiffness Index compared to European Caucasians (9.43(0.22) vs. 8.53(0.23) m/s, P = 0.007). In linear regression waist hip ratio and mean blood pressure were independent predictors of arterial stiffness (β = 0.26, P = 0.03). Conclusion South Asians have an increased wave reflection and systemic arterial stiffness compared to European Caucasians. Pathophysiological differences in vessel wall characteristics in South Asians may explain their increased susceptibility to higher cardiovascular risk and further work is warranted. Risk factor Mean (SD) South Asian European P Value (n = 90) Caucasian (n = 62) Mean age (years) 45.21(13.45) 46.76(11) 0.13 Body Mass Index(BMI)Kg/m2 25.9(3.2) 27.4(4.5) 0.08 Waist Hip Ratio(WHR) 0.94(0.08) 0.93(0.08) 0.53 Systolic blood pressure(mmHg) 134.56(20.3) 135.31(15.33) 0.82 Diastolic blood pressure(mmHg) 83.64(12.35) 83.58(10.09) 0.97 Serum cholesterol (mmol/l) 4.45(1.4) 4.66(0.72) 0.94 Fasting blood sugar(mmol/l) 4.99(1.4) 4.56(0.92) 0.43 P values using unpaired ttest comparing two groups

Despite attempts to maximize access to and receipt of health care in the UK, minority ethnic groups experience significant problems with non-culturally sensitive health care. ‘Linguistically and culturally diverse’ (LCD) groups continue, therefore, to bear a disease burden which is unacceptably high. This is particularly evident in cerebrovascular disease (CVD). The origin of exclusionary practices is discussed as is the epidemiology of CVD among Indian, Pakistani and Bangladeshi populations resident in the UK. There then follows a discussion of barriers to health care access, beliefs concerning health, medicine, illness and disease among LCD groups as possible predictors of access to health care. The central contention is that health care provided to CVD patients is flawed and indeed may exacerbate poor health outcomes as a result of discriminatory practices. Given this, models of nursing assessment and care are discussed. Finally, specific suggestions to enable staff to provide culturally sensitive care are provided and conclusions stated.

Measurements leading to the calculation of the standard thermodynamic properties in the gas phase for acridine, phenanthridine, and 7,8-benzoquinoline are reported. Thermochemical and thermophysical properties were determined by adiabatic heat-capacity calorimetry, comparative ebulliometry, inclined-piston manometry, and combustion calorimetry. Comparisons with literature values are presented and discussed. Results were used to calculate standard entropies, enthalpies, and Gibbs free energies of formation at selected temperatures to 500 K. Group-contribution methods were used to estimate the standard gas-phase entropy and enthalpy of formation at 400 K for the remaining two benzoquinolines: 5,6-benzoquinoline and 6,7-benzoquinoline. The relative stabilities of the compounds and comparisons with hydrocarbon analogues are discussed. A reaction scheme for the formation of the benzoquinolines is outlined and the mole fractions of the isomers are estimated for the reactions proceeding under thermodynamic control.