Hypertension (HT) is a 'by-product' to the forces of natural selection against environmental drift and salt availability, therefore contributed to differential HT susceptibility. This study provides further supporting evidence through: (i) associating three salt-sensitive related candidate gene variants, to the susceptibility of HT among the Malays from Peninsular Malaysia with a detail genotype-phenotype evaluation; (ii) comparing the blood pressure and the frequency spectrums of these variants across global populations; (iii) correlating them with the geographical coordinates and BP of the respective populations, and evaluating the presence of local adaptation in these candidate variants. We tested the genetic association of six SNPs underlying CYP11B2, AGT and ADRB2 in 918 normotensives and hypertensives Malays, men and women. CYP11B2 and ADRB2 were associated with elevated BP in males and females, respectively. Evaluation of these gene variations across 38 populations residing in different latitudinal clines revealed strong correlations between CYP11B2, AGT and latitudinal coordinates; whilst ADRB2 to a weaker extent. Tajima's D analyses suggested a non-neutral evolution on CYP11B2, which suggested a modest putative signals of local adaptation. In summary, we complement the notion that effective pharmacogenetic marker(s) to predict responsiveness of anti-HT medication requires comprehensive characterization of population genetics and HT phenotypes.

Background & objectives The results of the genetic association studies between the selected candidate genes and hypertension (HT) contradicted across different populations. Majority of the meta-analyses carried out did not consider population genetic ancestry as a confounding factor. Therefore, this meta-analysis attempted to consolidate and re-evaluate the findings of the association between the selected candidate variants (AGT-rs699, CYP11B2-rs1799998, ADRB2-rs1042713 and rs1042714) and HT, by categorizing the genotyping data based on known genetic ancestry, and/or major geographical populations. Methods Publications were retrieved from PubMed, Cochrane and World of Science. The included articles were further divided into different populations based on their known genetic and/or geographical ancestry. Results AGTrs699-G was significantly associated with HT among Indians for (i) allele [P=0.03, Odds ratio (OR): 1.37, 95% Confidence Interval (CI): 1.03–1.82], and (ii) dominant mode of inheritance (P=0.009, OR:1.45, 95% CI: 1.09–1.91). CYP11B2rs1799998-G was significantly associated with HT in Europeans for (i) allele (P=6.9 × 10–5, OR: 0.82, 95% CI: 0.74–0.9), (ii) recessive (P=6.38 × 10-5, OR: 0.7, 95% CI: 0.59–0.83) and (iii) dominant mode of inheritance (P=0.008, OR: 0.81, 95% CI: 0.7–0.94). ADRB2-rs1042713-G was significantly associated with HT in east Asians for (i) allele (P=0.01, OR: 1.26, 95% CI: 1.05–1.51), and (ii) recessive mode of inheritance (P=0.04, OR: 1.36, 95% CI: 1.01–1.83). Interpretation & conclusions Different genotype and allele frequencies in diverse populations result in different genetic associations with HT across populations. This meta-analysis finding provides an update and summary of the genetic association between the selected simple nucleotide polymorphism (SNPs) and HT across different populations and essential insights into selecting appropriate pharmacogenetic marker(s) for effective HT management in populations of different ancestries.

Background:Smoking is a major risk factor for the global burden of stroke. We have previously reported a global population attributable risk (PAR) of stroke of 12.4% associated with current smoking. In this study we aimed to explore the association of current tobacco use with different types of tobacco exposure and environmental tobacco smoke (ETS) exposure on the risk of stroke and stroke subtypes, and by regions and country income levels. Methods:The INTERSTROKE study is a case-control study of acute first stroke and was undertaken with 13,462 stroke cases and 13,488 controls recruited between January 11, 2007 and August 8, 2015 in 32 countries worldwide. Association of risk of tobacco use and ETS exposure were analysed with overall stroke, ischemic and intracerebral hemorrhage (ICH), and with TOAST etiological stroke subtypes (large vessel, small vessel, cardioembolism, and undetermined). Findings:Current smoking was associated with an increased risk of all stroke (odds ratio [OR] 1.64, 95% CI 1.46-1.84), and had a stronger association with ischemic stroke (OR 1.85, 95% CI 1.61-2.11) than ICH (OR 1.19 95% CI 1.00-1.41). The OR and PAR of stroke among current smokers varied significantly between regions and income levels with high income countries (HIC) having the highest odds (OR 3.02 95% CI 2.24-4.10) and PAR (18.6%, 15.1-22.8%). Among etiological subtypes of ischemic stroke, the strongest association of current smoking was seen for large vessel stroke (OR 2.16, 95% CI 1.63-2.87) and undetermined cause (OR 1.97, 95% CI 1.55-2.50). Both filtered (OR 1.73, 95% CI 1.50-1.99) and non-filtered (OR 2.59, 95% CI 1.79-3.77) cigarettes were associated with stroke risk. ETS exposure increased the risk of stroke in a dose-dependent manner, exposure for more than 10 h per week increased risk for all stroke (OR 1.95, 95% CI 1.69-2.27), ischemic stroke (OR 1.89, 95% CI 1.59-2.24) and ICH (OR 2.00, 95% CI 1.60-2.50). Interpretation:There are significant variations in the magnitude of risk and PAR of stroke according to the types of tobacco used, active and ETS exposure, and countries with different income levels. Specific strategies to discourage tobacco use by any form and to build a smoke free environment should be implemented to ease the global burden of stroke. Funding:The Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, and through unrestricted grants from several pharmaceutical companies with major contributions from Astra Zeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MERCK, Sharp and Dohme, Swedish Heart and Lung Foundation, UK Chest, and UK Heart and Stroke.

Background and Objectives Symptoms of sleep disturbance are common and may represent important modifiable risk factors of stroke. We evaluated the association between a spectrum of sleep disturbance symptoms and the risk of acute stroke in an international setting. Methods The INTERSTROKE study is an international case-control study of patients presenting with first acute stroke and controls matched by age (±5 years) and sex. Sleep symptoms in the previous month were assessed through a questionnaire. Conditional logistic regression estimated the association between sleep disturbance symptoms and acute stroke, expressed as odds ratios (ORs) and 95% CIs. The primary model adjusted for age, occupation, marital status, and modified Rankin scale at baseline, with subsequent models adjusting for potential mediators (behavioral/disease risk factors). Results Overall, 4,496 matched participants were included, with 1,799 of them having experienced an ischemic stroke and 439 an intracerebral hemorrhage. Short sleep (<5 hours: OR 3.15, 95% CI 2.09–4.76), long sleep (>9 hours: OR 2.67, 95% CI 1.89–3.78), impaired quality (OR 1.52, 95% CI 1.32–1.75), difficulty getting to sleep (OR 1.32, 95% CI 1.13–1.55) or maintaining sleep (OR 1.33, 95% CI 1.15–1.53), unplanned napping (OR 1.48, 95% CI 1.20–1.84), prolonged napping (>1 hour: OR 1.88, 95% CI 1.49–2.38), snoring (OR 1.91, 95% CI 1.62–2.24), snorting (OR 2.64, 95% CI 2.17–3.20), and breathing cessation (OR 2.87, 95% CI 2.28–3.60) were all significantly associated with an increased odds of acute stroke in the primary model. A derived obstructive sleep apnea score of 2–3 (2.67, 2.25–3.15) and cumulative sleep symptoms (>5: 5.38, 4.03–7.18) were also associated with a significantly increased odds of acute stroke, with the latter showing a graded association. After an extensive adjustment, significance was maintained for most of the symptoms (not difficulty getting to/maintaining sleep and unplanned napping), with similar findings for stroke subtypes. Discussion We found that sleep disturbance symptoms were common and associated with a graded increased risk of stroke. These symptoms may be a marker of increased individual risk or represent independent risk factors. Future clinical trials are warranted to determine the efficacy of sleep interventions in stroke prevention.

Background and Purpose The association of dyslipidemia with stroke has been inconsistent, which may be due to differing associations within etiological stroke subtypes. We sought to determine the association of lipoproteins and apolipoproteins within stroke subtypes. Methods Standardized incident case-control STROKE study in 32 countries. Cases were patients with acute hospitalized first stroke, and matched by age, sex and site to controls. Concentrations of total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein A1 (apoA1), and apoB were measured. Non-HDL-C was calculated. We estimated multivariable odds ratio (OR) and population attributable risk percentage (PAR%). Outcome measures were all stroke, ischemic stroke (and subtypes), and intracerebral hemorrhage (ICH). Results Our analysis included 11,898 matched case-control pairs; 77.3% with ischemic stroke and 22.7% with ICH. Increasing apoB (OR, 1.10; 95% confidence interval [CI], 1.06 to 1.14 per standard deviation [SD]) and LDL-C (OR, 1.06; 95% CI, 1.02 to 1.10 per SD) were associated with an increase in risk of ischemic stroke, but a reduced risk of ICH. Increased apoB was significantly associated with large vessel stroke (PAR 13.4%; 95% CI, 5.6 to 28.4) and stroke of undetermined cause. Higher HDL-C (OR, 0.75; 95% CI, 0.72 to 0.78 per SD) and apoA1 (OR, 0.63; 95% CI, 0.61 to 0.66 per SD) were associated with ischemic stroke (and subtypes). While increasing HDL-C was associated with an increased risk of ICH (OR, 1.20; 95% CI, 1.14 to 1.27 per SD), apoA1 was associated with a reduced risk (OR, 0.80; 95% CI, 0.75 to 0.85 per SD). ApoB/A1 (OR, 1.38; 95% CI, 1.32 to 1.44 per SD) had a stronger magnitude of association than the ratio of LDL-C/HDL-C (OR, 1.26; 95% CI, 1.21 to 1.31 per SD) with ischemic stroke (P<0.0001). Conclusions The pattern and magnitude of association of lipoproteins and apolipoproteins with stroke varies by etiological stroke subtype. While the directions of association for LDL, HDL, and apoB were opposing for ischemic stroke and ICH, apoA1 was associated with a reduction in both ischemic stroke and ICH. The ratio of apoB/A1 was the best lipid predictor of ischemic stroke risk.

Diabetic cardiomyopathy (DCM) is defined by the abnormal myocardial structure and performance in the absence of other cardiac risk factors in individuals with diabetes mellitus. Diabetics are at higher risk of developing heart failure and suffer from a significantly higher rate of mortality in comparison to those without DM. Being a nation with the highest rate of obesity in South East Asia, it is important to determine the prevalence and outcome in the Malaysian cohort.

High sodium intake was found to be associated with increased blood pressure. Decreasing dietary sodium intake can effectively reduce blood pressure, especially among hypertensive individuals, but the extent of reduction remains debatable. The effectiveness of different sodium reduction strategies on blood pressure reduction was identified in the current review. Randomized controlled trials and clinical trials on dietary sodium intake and blood pressure published from 23 March 2008 to 23 March 2021 were collected from the PubMed database. Twenty-six studies were included and divided into four subgroups based on the types of interventions identified. Subgroups included a low-sodium diet (1) in a group with or without added sodium, (2) through food substitutes, (3) through health education and behavior change, and (4) through salt substitutes. Reduction of dietary sodium intake resulted in a mean difference of 4.51 mmHg (95% CI: 3.35–5.67) in systolic blood pressure and 2.42 mmHg (95% CI: 1.61–3.23) in diastolic blood pressure. The effectiveness of these strategies was approximated from the difference in 24-h urinary sodium excretion between the intervention and control groups, which was 53.74 mmol/day (95% CI: 31.95–75.53). When analyzed, the low-sodium diet without added sodium showed the greatest significant differences in blood pressure (7.58/4.01 mmHg) and 24-h urinary sodium excretion (101.49 mmol/day), whereas the low-sodium diet through food substitutes yielded the lowest significant differences in blood pressure (2.26/0.81 mmHg) and 24-h urinary sodium excretion (25.78 mmol/day). Thus, reducing sodium intake can be an effective strategy for the prevention and treatment of hypertension.

BACKGROUND AND AIMS:Vitamin D has mostly been tested in Western populations. We examined the effect of high dose vitamin D in a population drawn predominantly from outside of Western countries. METHODS AND RESULTS:This randomized trial tested vitamin D 60,000 IU monthly in 5670 participants without vascular disease but at increased CV risk. The primary outcome was fracture. The secondary outcome was the composite of CV death, myocardial infarction stroke, cancer, fracture or fall. Death was a pre-specified outcome. Mean age was 63.9 years, and 3005 (53.0%) were female. 3034 (53.5%) participants resided in South Asia, 1904 (33.6%) in South East Asia, 480 (8.5%) in South America, and 252 (4.4%) in other regions. Mean follow-up was 4.6 years. A fracture occurred in 20 participants (0.2 per 100 person years) assigned to vitamin D, and 19 (0.1 per 100 person years) assigned to placebo (HR 1.06, 95% CI 0.57-1.99, p-value = 0.86). The secondary outcome occurred in 222 participants (1.8 per 100 person years) assigned to vitamin D, and 198 (1.6 per 100 person years) assigned to placebo (HR 1.13, 95% CI 0.93-1.37, p = 0.22). 172 (1.3 per 100 person years) participants assigned to vitamin D died, compared with 135 (1.0 per 100 person years) assigned to placebo (HR 1.29, 95% CI 1.03-1.61, p = 0.03). CONCLUSION:In a population predominantly from South Asia, South East Asia and South America, high-dose vitamin D did not reduce adverse skeletal or non-skeletal outcomes. Higher mortality was observed in the vitamin D group. REGISTRATION NUMBER:NCT01646437.

Excessive salt consumption has been associated with greater risk of hypertension. Therefore, monitoring of dietary sodium consumption should be prioritized. As sodium is mainly excreted through urine, 24-h urine sample can be used to estimate individual sodium intake. Thus, a simple and inexpensive semi-quantitative urinary sodium detection test strip was developed based on the enzymatic reaction between β-galactosidase and chlorophenol red-β-d-galactopyranoside. When tested, color formation was distinguished at 0 M (chartreuse yellow), 0.05 M (sunflower), 0.1-0.15 M (mango tango), and 0.2-0.25 M (persimmon) sodium. Analysis from ImageJ showed a linear result (r2 > 0.9), low SD, and significant increase in magenta difference (p < 0.01) between 0 and 0.05-0.25 M sodium. Test strip can detect 0.03 M sodium at minimum but did not last for >2 days in adverse storage conditions (laboratory conditions, ∼80% relative humidity, 40°C, and direct light exposure) when stored in test strip bottles, and even shorter when exposed to the environment. The presence of urinary potassium, urea, and glucose did not affect test strip performance. Test strip produced comparable results to flame photometry with <15% variation when tested on overnight, random spot, and 24-h urine samples. Overall, the developed test strip can be used to enzymatically semi-quantify 0.05-0.25 M sodium.

Background Traditional, complementary and alternative medicine (TCAM) is used to treat a broad range of conditions. In low- and middle-income countries (LMICs), TCAM use is particularly common among those with low socio-economic status. To better understand the patterns and impact of TCAM use on the management of non-communicable diseases in these populations, this study examines the prevalence and characteristics of TCAM use for hypertension, its determinants, and its association with hypertension management outcomes and wellbeing among low-income adults in two Southeast Asian countries at different levels of economic and health system development, Malaysia and the Philippines. Methods We analysed cross-sectional data from 946 randomly selected adults diagnosed with hypertension from low-income rural and urban communities in Malaysia (n = 495) and the Philippines (n = 451). We compared the prevalence, characteristics and household expenditure on TCAM use between countries and used multi-level, mixed-effects regression to estimate associations between TCAM use and its determinants, and five hypertension management outcomes and wellbeing. Results The prevalence of TCAM use to manage hypertension was higher in the Philippines than in Malaysia (18.8% vs 8.8%, p < 0.001). Biologically-based modalities, e.g. herbal remedies, were the most common type of TCAM used in both countries, mainly as a complement, rather than an alternative to conventional treatment. Households allocated around 10% of health spending to TCAM in both countries. Belief that TCAM is effective for hypertension was a positive predictor of TCAM use, while belief in conventional medicine was a negative predictor. TCAM use was not strongly associated with current use of medications for hypertension, self-reported medication adherence, blood pressure level and control, or wellbeing in either country. Conclusions A small, but significant, proportion of individuals living in low-income communities in Malaysia and the Philippines use TCAM to manage their hypertension, despite a general lack of evidence on efficacy and safety of commonly used TCAM modalities. Recognising that their patients may be using TCAM to manage hypertension will enable health care providers to deliver safer, more patient-centred care.

Physical activity (PA) in the form of structured or unstructured exercise is beneficial for health. This paper aims to study PA levels across four domains according to the International Physical Activity Questionnaire (IPAQ) and its associated factors. A total of 7479 Malaysian adult participants between 18 to 90 years old from the REDISCOVER study who completed the IPAQ were analyzed. PA was calculated as MET-min per week and were categorized according to insufficiently active, sufficiently active and very active. Multinomial regression was used to determine the association between sociodemographic, clinical factors and the level of PA. The mean age of the participants was 51.68 (±9.5 SD). The total reported physical activity in median (IQR) was 1584.0 (0–5637.3) MET-min per week. The highest total for PA was in the domestic domain which is 490 (0–2400) MET-min per week. Factors associated with sufficiently active or very active PA include Malay ethnicity, no formal education, elementary occupation, current smokers and high HDL. Whereas low income, male and normal BMI are less likely to participate in sufficiently active or very active PA. Intervention to encourage higher PA levels in all domains is important to achieve recommended PA targets.

ABSTRACTLeft Ventricular Hypertrophy (LVH) is a risk for various cardiovascular events among those with hypertension (HT). However the prevalence of hypertension-related LVH (HT LVH+) in communities with lower socioeconomic status (SES) is not adequately reported. This study investigated the prevalence of HT LVH+ among the urban and rural males and the attributing factors. A total of 1,923 males who had echocardiographic examinations done were recruited. Their blood pressure was measured to diagnose those with or without hypertension. Left ventricular mass index was determined. Univariate analysis was performed to identify associated factors predisposing to LVH. A total of 992 males had HT, of which 264 had LVH, and were more prevalent in older age groups and Malays (p<0.001). Individuals from rural areas, with low income and low educational background were associated with higher LVH prevalence (p<0.001). Those with moderate aortic regurgitation was 3.17-fold higher in LVH. Ninety-nine normotensives had LVH, 71.7% came from rural. Total cholesterol and low density lipoprotein cholesterol levels were significantly higher in HT LVH+ from urban than the rural areas (p=0.029 and p=0.002, respectively). A quarter of the HT population in Malaysia develop LVH, majority of them were from rural, indicating that socioeconomic disparities contribute to the higher risk of HT LVH+. The rural populations may have attributed to different risk factors as opposed to those from urban, hence emphasize the need to deliver targeted strategies for prevention and management HT LVH+ by different SES.

Abstract Aims Rosuvastatin (10 mg per day) compared with placebo reduced major adverse cardiovascular (CV) events by 24% in 12 705 participants at intermediate CV risk after 5.6 years. There was no benefit of blood pressure (BP) lowering treatment in the overall group, but a reduction in events in the third of participants with elevated systolic BP. After cessation of all the trial medications, we examined whether the benefits observed during the active treatment phase were sustained, enhanced, or attenuated. Methods and results After the randomized treatment period (5.6 years), participants were invited to participate in 3.1 further years of observation (total 8.7 years). The first co-primary outcome for the entire length of follow-up was the composite of myocardial infarction, stroke, or CV death [major adverse cardiovascular event (MACE)-1], and the second was MACE-1 plus resuscitated cardiac arrest, heart failure, or coronary revascularization (MACE-2). In total, 9326 (78%) of 11 994 surviving Heart Outcomes Prevention Evaluation (HOPE)-3 subjects consented to participate in extended follow-up. During 3.1 years of post-trial observation (total follow-up of 8.7 years), participants originally randomized to rosuvastatin compared with placebo had a 20% additional reduction in MACE-1 [95% confidence interval (CI), 0.64–0.99] and a 17% additional reduction in MACE-2 (95% CI 0.68–1.01). Therefore, over the 8.7 years of follow-up, there was a 21% reduction in MACE-1 (95% CI 0.69–0.90, P = 0.005) and 21% reduction in MACE-2 (95% CI 0.69–0.89, P = 0.002). There was no benefit of BP lowering in the overall study either during the active or post-trial observation period, however, a 24% reduction in MACE-1 was observed over 8.7 years. Conclusion The CV benefits of rosuvastatin, and BP lowering in those with elevated systolic BP, compared with placebo continue to accrue for at least 3 years after cessation of randomized treatment in individuals without cardiovascular disease indicating a legacy effect. Trial Registration Number NCT00468923

Diabetic cardiomyopathy (DCM) is defined as the presence of specific cardiac manifestations that lead to heart failure in a diabetic in the absence of significant coronary artery disease and valvular disease. It affects between 16.9 and 74% of diabetics. The prevalence of DCM is not known in Malaysia. Being a nation with the highest rate of obesity in South East Asia, knowledge of its prevalence may help project a plan for better healthcare management and health outcome. Objective: To determine the prevalence of DCM in the Malaysian cohort.

In Malaysia, the prevalence of DM reportedly increased two-fold to 22.9% from 2006 to 2013. In 2015, the Malaysian National Health & Morbidity Survey reported 17.5% of adults above 18 years old were diabetic, about half of which (9.2%) were newly diagnosed. Given the rise of obesity affecting 17.7% of Malaysians in contrast to the world's obese adult population of 13%, the current prevalence of DM in Malaysia is expected to be even higher. Diabetics are at a 74% risk of developing clinical heart failure and suffer from a significantly higher rate of mortality in comparison to those without DM.

BACKGROUND Most data regarding the association between the glycemic index and cardiovascular disease come from high-income Western populations, with little information from non-Western countries with low or middle incomes. To fill this gap, data are needed from a large, geographically diverse population. METHODS This analysis includes 137,851 participants between the ages of 35 and 70 years living on five continents, with a median follow-up of 9.5 years. We used country-specific food-frequency questionnaires to determine dietary intake and estimated the glycemic index and glycemic load on the basis of the consumption of seven categories of carbohydrate foods. We calculated hazard ratios using multivariable Cox frailty models. The primary outcome was a composite of a major cardiovascular event (cardiovascular death, nonfatal myocardial infarction, stroke, and heart failure) or death from any cause. RESULTS In the study population, 8780 deaths and 8252 major cardiovascular events occurred during the follow-up period. After performing extensive adjustments comparing the lowest and highest glycemic-index quintiles, we found that a diet with a high glycemic index was associated with an increased risk of a major cardiovascular event or death, both among participants with preexisting cardiovascular disease (hazard ratio, 1.51; 95% confidence interval [CI], 1.25 to 1.82) and among those without such disease (hazard ratio, 1.21; 95% CI, 1.11 to 1.34). Among the components of the primary outcome, a high glycemic index was also associated with an increased risk of death from cardiovascular causes. The results with respect to glycemic load were similar to the findings regarding the glycemic index among the participants with cardiovascular disease at baseline, but the association was not significant among those without preexisting cardiovascular disease. CONCLUSIONS In this study, a diet with a high glycemic index was associated with an increased risk of cardiovascular disease and death. (Funded by the Population Health Research Institute and others.).

Importance Cohort studies report inconsistent associations between fish consumption, a major source of long-chain ω-3 fatty acids, and risk of cardiovascular disease (CVD) and mortality. Whether the associations vary between those with and those without vascular disease is unknown. Objective To examine whether the associations of fish consumption with risk of CVD or of mortality differ between individuals with and individuals without vascular disease. Design, Setting, and Participants This pooled analysis of individual participant data involved 191 558 individuals from 4 cohort studies-147 645 individuals (139 827 without CVD and 7818 with CVD) from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study and 43 413 patients with vascular disease in 3 prospective studies from 40 countries. Adjusted hazard ratios (HRs) were calculated by multilevel Cox regression separately within each study and then pooled using random-effects meta-analysis. This analysis was conducted from January to June 2020. Exposures Fish consumption was recorded using validated food frequency questionnaires. In 1 of the cohorts with vascular disease, a separate qualitative food frequency questionnaire was used to assess intake of individual types of fish. Main Outcomes and Measures Mortality and major CVD events (including myocardial infarction, stroke, congestive heart failure, or sudden death). Results Overall, 191 558 participants with a mean (SD) age of 54.1 (8.0) years (91 666 [47.9%] male) were included in the present analysis. During 9.1 years of follow-up in PURE, compared with little or no fish intake (≤50 g/mo), an intake of 350 g/wk or more was not associated with risk of major CVD (HR, 0.95; 95% CI, 0.86-1.04) or total mortality (HR, 0.96; 0.88-1.05). By contrast, in the 3 cohorts of patients with vascular disease, the HR for risk of major CVD (HR, 0.84; 95% CI, 0.73-0.96) and total mortality (HR, 0.82; 95% CI, 0.74-0.91) was lowest with intakes of at least 175 g/wk (or approximately 2 servings/wk) compared with 50 g/mo or lower, with no further apparent decrease in HR with consumption of 350 g/wk or higher. Fish with higher amounts of ω-3 fatty acids were strongly associated with a lower risk of CVD (HR, 0.94; 95% CI, 0.92-0.97 per 5-g increment of intake), whereas other fish were neutral (collected in 1 cohort of patients with vascular disease). The association between fish intake and each outcome varied by CVD status, with a lower risk found among patients with vascular disease but not in general populations (for major CVD, I2 = 82.6 [P = .02]; for death, I2 = 90.8 [P = .001]). Conclusions and Relevance Findings of this pooled analysis of 4 cohort studies indicated that a minimal fish intake of 175 g (approximately 2 servings) weekly is associated with lower risk of major CVD and mortality among patients with prior CVD but not in general populations. The consumption of fish (especially oily fish) should be evaluated in randomized trials of clinical outcomes among people with vascular disease.

Hypertension is a major modifiable determinant of the increasing burden of cardiovascular diseases in Malaysia.When not controlled it increases the risk of heart disease, stroke, and renal disease.This paper, a contribution to development of an effective response to this challenge, reviews what is known about the prevalence, awareness, treatment and control of hypertension in Malaysia, identifying the factors contributing to inadequate levels of control and feasible measures to improve it.It reviews published data from Malaysia -with reference to other countries where relevant -to offer a comprehensive understanding of the problem.It is apparent that managing hypertension goes beyond the mere prescription of blood pressure (BP) lowering drugs.It involves a complex interplay of the healthcare delivery system, healthcare providers, and patients, recognising their differing educational, psychosocial, economic and residential status.Thus a one-size-fits-all approach will be patently inadequate to achieve good hypertension control.A paradigm shift towards a care for hypertension in Malaysia is needed.

Key Points Question Is late bedtime associated with general and abdominal obesity and does a heterogonous association exist between men and women? Findings In this cross-sectional study of 136 652 participants from 26 countries from the Prospective Urban Rural Epidemiology study, after adjustment for a wide range of potential confounding factors, late nocturnal bedtime and short nocturnal sleep were associated with increased risk of general and abdominal obesity, while longer daytime napping could not compensate for the loss but further increased risk of abdominal obesity, especially among women. Meaning These findings suggest that encouraging earlier bedtime and avoiding short nocturnal sleep may benefit weight control.