Strategies to prevent cardiovascular disease in Singapore: A call to action from Singapore Heart Foundation, Singapore Cardiac Society and Chapter of Cardiologists of the Academy of Medicine, Singapore.

Introduction: In 2022, the Minister for Health of Singapore launched Healthier SG, a national strategy in championing the shift towards a population health approach. Method: The Singapore Heart Foundation conducted a series of roundtable discussions, also attended by representatives of the Singapore Cardiac Society and the Chapter of Cardiologists of the Academy of Medicine Singapore. During the meetings, the authors formulated interventions supportive of Healthier SG that specifically aimed to uplift the state of cardiovascular (CV) preventive care in Singapore. Results: In line with Healthier SG, the authors propose a 3-pronged approach ("Healthier Heart SG") to augment the success of Healthier SG in achieving good CV outcomes. This proposal includes the following components: (1) a call to update the standards of care in addressing the 5 main modifiable risk factors of cardiovascular disease (CVD); (2) patient education through cooperation between healthcare professionals and community partners for a whole-of-system approach; and (3) support for integrated care, including access to cardiac rehabilitation in the community, improved referral processes and access to nutrition/dietetics counselling and tobacco cessation, optimal use of information technology, and continued CV research. Conclusion: Healthier Heart SG would bring the standards of care and CV care delivery in Singapore closer to achieving the vision of proactive prevention of CVD and CV morbidity and mortality. This can only be achieved through the concerted efforts of healthcare professionals, policymakers and community partners, coupled with the cooperation of community members.

Patterns of motivators and barriers to heart health behaviors among adults with behavior-modifiable cardiovascular risk factors: A population-based survey in Singapore.

OBJECTIVES: Motivators and barriers are pivotal factors in the adoption of health behaviors. This study aims to identify patterns of the motivators and barriers influencing heart health behaviors among multi-ethnic Asian adults with behavior-modifiable risk factors for heart disease, namely obesity, physical inactivity and smoking. METHODS: A population-based survey of 1,000 participants was conducted in Singapore. Participants were assessed for behavior-modifiable risk factors and asked about motivators and barriers to heart health behaviors. Exploratory and confirmatory factor analyses were conducted to identify factors underlying motivator and barrier question items. Logistic regression was conducted to examine the associations of motivator and barrier factors with sociodemographic characteristics. RESULTS: The twenty-five motivator and barrier items were classified into three (outcome expectations, external cues and significant others including family and friends) and four (external circumstances, limited self-efficacy and competence, lack of perceived susceptibility, benefits and intentions and perceived lack of physical capability) factors respectively. Among participants with behavior-modifiable risk factors, those with lower education were more likely to be low in motivation factor of "outcome expectations" and "external cues". The well-educated were more likely to be high in the barrier factor of "lack of perceived susceptibility, benefits and intention" and were less likely to have the motivation factor of "significant others (family or friends)". Those aged 60-75 years had low motivations and high barriers compared to their younger counterparts. Older age was more likely to be low in motivation factor of "outcome expectations" and "external cues" and high in barrier factor of "limited self-efficacy and competence" and "perceived lack of physical capability". CONCLUSIONS: Findings underscore the importance of a targeted intervention and communication strategy addressing specific motivation and barrier factors in different population segments with modifiable risk factors.

Public perceptions and knowledge of cholesterol management in a multi-ethnic Asian population: A population-based survey.

INTRODUCTION: Cardiovascular diseases (CVDs) are the leading cause of mortality worldwide. Hyperlipidemia is one of the important modifiable risk factors for CVDs. Raising public awareness of CVD risks is an important step in reducing CVD burdens. In this study, we aimed to assess public awareness and knowledge of cholesterol and its management in a multiethnic Asian population. METHODS: We recruited 1000 participants from three major ethnic groups for this nationwide population-based survey. A structured questionnaire was used to collect socio-demographics, knowledge of cholesterol and cholesterol-lowering medications. Univariate and multivariate analyses were conducted to identify factors associated with good knowledge on cholesterol and its management. RESULTS: Of the participants, 65% thought that high cholesterol produces symptoms and that lifestyle modification would be as effective as medication at lowering cholesterol. Nearly 70% believed that long term statin could lead to kidney or liver damage, and 56% thought that statin was associated with higher risk of cancer. A third saw herbal medicine or supplements as healthier and safer. About 45% believed that statin therapy should not be taken long term and that one could stop taking cholesterol medication when cholesterol is under control. Malays were more likely to have poor knowledge (adjusted OR 0.68; 95% CI 0.47-0.98; P = 0.039) compared to Chinese. Participants with intermediate education were more likely to have good knowledge of cholesterol and its management (adjusted OR 1.67; 95% CI 1.11-2.51; P = 0.013) compared to those with primary education. CONCLUSION: Public knowledge and awareness of high cholesterol and its management remains poor in Asian multi-ethnic population. Understanding gaps in public knowledge can inform the implementation of health promotion programs to effectively raise awareness of cholesterol and its management.

Elderly Asian Patients Have Lower Revascularisation Rates and Poorer Outcomes for ST-Elevation Myocardial Infarction Compared to Younger Patients.

INTRODUCTION: There is limited information on elderly patients presenting with ST- elevation myocardial infarction (STEMI). This study aimed to study the outcomes of elderly Asian patients with STEMI compared to younger patients. MATERIALS AND METHODS: The study utilised data from 2007 to 2012 from the Singapore Myocardial Infarction Registry, a mandatory national population-based registry. Elderly patients were defined as ≥80 years of age, middle-aged to old (MAO) patients were defined as 45-80 years of age and young patients were defined as ≤45 years of age. The primary outcome of the study was 1-year mortality and secondary outcomes included in-hospital complications and mortality. RESULTS: There were 12,409 STEMI patients with 1207 (9.7%) elderly patients, 10,093 (81.3%) MAO patients and 1109 (8.9%) young patients. Elderly patients had more cardiovascular risk factors and lower rates of total percutaneous coronary intervention (26.0% vs 72.4% vs 85.5%, respectively; P <0.0001) compared to MAO and young patients. They had higher 1-year mortality (60.6% vs 18.3% vs 4.1%, respectively; P <0.0001) when compared to MAO and young patients. CONCLUSION: Elderly patients with STEMI have poorer outcomes than MAO and young patients. This is potentially attributable to a myriad of factors including age, higher burden of comorbidities and a lesser likelihood of receiving revascularisation and guideline-recommended medical therapy.

Ministry of Health Clinical Practice Guidelines: Hypertension.

The Ministry of Health (MOH) has updated the clinical practice guidelines on hypertension to provide doctors and patients in Singapore with evidence-based treatment for hypertension. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on hypertension, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Comparative analysis of recurrent events after presentation with an index myocardial infarction or ischaemic stroke.

Aims: Acute myocardial infarction (AMI) and stroke are important causes of mortality and morbidity. Our aims are to determine the comparative epidemiology of AMI and ischaemic stroke; and examine the differences in cardiovascular outcomes or mortality occurring after an AMI or stroke. Methods and results: The Singapore National Registry of Diseases Office collects countrywide data on AMI, stroke, and mortality. Index events of AMI and ischaemic stroke between 2007 and 2012 were identified. Patients were then matched for occurrences of subsequent AMI, stroke, or death within 1-year of the index event. There were 33 222 patients with first-ever AMI and 20 982 with first-ever stroke. AMI patients were significantly more likely to be men (66.3% vs. 56.9%), non-Chinese (32.1% vs. 24.1%), and smokers (43.1% vs. 38.6%), but less likely to have hypertension (65.6% vs. 79%) and hyperlipidaemia (61.1% vs. 65.5%), compared with stroke patients. In total 6.8% of the AMI patients had recurrent AMI, whereas 4.8% of the stroke patients had recurrent stroke within 1 year; 31.7% of the AMI patients died, whereas 17.1% of the ischaemic stroke patients died within 1 year. Older age, Malay ethnicity, and diabetes mellitus were statistically significant risk factors for all-cause mortality and for the composite endpoint of AMI, stroke, and all-cause mortality, at 1 year. Conclusions: Risk profiles of patients with AMI and stroke are significantly different. Patients suffer recurrent events in vascular territories similar to the index event. Age and diabetes mellitus are significant predictors of recurrent vascular events and mortality.

Ministry of Health Clinical Practice Guidelines: Lipids.

The Ministry of Health (MOH) has updated the Clinical Practice Guidelines on Lipids to provide doctors and patients in Singapore with evidence-based treatment for lipids. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH Clinical Practice Guidelines on Lipids, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html.

Hypertension treatment in the Asia-Pacific: the role of and treatment strategies with nebivolol.

Hypertension is a common disease, and hypertensive patients are at increased risk of cardiovascular events. The prevalence and socioeconomic burden of hypertension in the Asia-Pacific region are predicted to increase in the coming decades. Effective blood pressure lowering reduces overall cardiovascular morbidity and mortality in patients, yet doubt has been raised regarding the use of (mainly older generation) ß-blockers as initial therapy in hypertension. Consequently, several international treatment guidelines do not recommend ß-blockers for the treatment of hypertension. However, in contrast to first-generation and second-generation ß-blockers, the third-generation, vasodilating ß-blocker nebivolol has a considerably better metabolic, haemodynamic and side effect profile. In addition to providing effective blood pressure control similar to other ß-blockers and drugs from other antihypertensive classes, nebivolol exerts a dual mechanism for increasing the bioavailability of the naturally occurring vasodilator nitric oxide. The clinical benefits and significance of enhancing nitric oxide levels in hypertensive patients have been shown in direct comparisons of nebivolol with other ß-blockers. While ß-blockers generally provide comparable blood pressure reductions, only nebivolol demonstrated enhanced vasodilation and blood flow by increasing the expression of endothelial nitric oxide synthase and therefore increasing nitric oxide release from the endothelium. In contrast to other ß-blockers, therefore, it has been suggested that nebivolol has beneficial effects in several hypertensive subgroups due to its vasodilating properties. Considering the existing data, it may be timely for treatment guidelines to recommend third-generation vasodilating ß-blockers as a first-line option for the pharmacotherapy of hypertension.

The use of medications in the secondary prevention of coronary artery disease in the Asian region.

BACKGROUND: Cardiovascular diseases, to which coronary artery disease (CAD) is a significant contributor, are a leading cause of long-term morbidity and mortality worldwide. In the years ahead, it is estimated that approximately half of the world's cardiovascular burden will occur in the Asian region. Currently there is a large gap in secondary prevention, with unrealized health gains resulting from underuse of evidence-based medications, including beta-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), aspirin and other antiplatelet agents, and lipid-lowering drugs. Despite the almost universal recommendation for these drugs in unstable CAD, their under-prescription is well documented for patients with acute heart failure, non-obstructive CAD, and for secondary prevention of CAD. OBJECTIVE: This article reviews the burden of CAD in Asian countries together with guidelines supporting evidence-based medication use from a secondary prevention perspective. METHODS: The MEDLINE database was searched from 2000 to 2013, inclusive, for country-specific data related to CAD and supplemented with unpublished registry data. RESULTS: In the post-discharge setting following hospital admission for acute coronary syndromes, medication prescription rates were low. Beta-blocker prescription rates ranged from 49% in China to 99% in Singapore, ACE-inhibitor/ARB prescription rates ranged from 28% in China to 96% in Singapore, and lipid-lowering therapy rates ranged from 47% in China to 97% in Singapore. Aspirin/antiplatelet drug prescription rates ranged from 86% in Indonesia to 99.5% in Singapore. Recommendations are provided to improve patient outcomes and reduce the disease burden in Asia. CONCLUSIONS: Despite recommendations issued in international and national guidelines, use of CAD medications in Asia remains suboptimal. In the absence of clear contraindications, all patients with unstable CAD should receive these agents as secondary prevention. This averts the need to target drug use according to risk, with high-risk features paradoxically associated with under-prescribing of such drugs.

Public perceptions, knowledge and awareness of cholesterol management in Singapore: a prospective pilot study.

INTRODUCTION: Hyperlipidaemia is a major risk factor for coronary artery disease (CAD). Its effective treatment has been shown to reduce the incidence of cardiovascular events, both in secondary and primary prevention. An essential component of risk factor management at the community level is public awareness and knowledge of treatment benefits. However, this data is limited in Singapore. METHODS: A cross-sectional survey questionnaire of public perception and knowledge on cholesterol treatment among adult Singaporeans aged 30-69 years was commissioned by the Singapore Heart Foundation and conducted by a professional market survey company. Regional quota sampling was performed to ensure that the sample was representative of the Singapore population. This was followed by random sampling of households and respondents. RESULTS: Of the 365 respondents, 40.9% were male, 70.3% were Chinese, 18.8% Malay and 10.9% Indian. The mean age was 47.5 years. Although 81.9% of respondents had medical check-ups involving blood tests, only 11.0% knew their actual cholesterol levels. A third of the respondents saw herbal medicine as healthier and safer than Western medication. More than 80% of respondents believed that diet and exercise were equally effective at lowering cholesterol as medication. About half of the respondents associated long-term use of statins with damage to the liver and kidney, while a third associated chronic statin use with the development of cancer. CONCLUSION: There are gaps in the level of public awareness and understanding of cholesterol treatment in Singapore. Common misconceptions should be addressed, as they could potentially impair effective management or treatment compliance.

Effects of rosuvastatin on low-density lipoprotein cholesterol and plasma lipids in Asian patients with hypercholesterolemia.

AIMS: Rosuvastatin is more efficacious than other statins in lowering low-density lipoprotein cholesterol (LDL-C). Studies showing higher blood levels in Asians have resulted in concerns regarding increased adverse drug reactions. This study aimed to evaluate the efficacy and safety of rosuvastatin in hypercholesterolemic Asian patients. METHODS: This retrospective observational study was conducted on statin-naive patients and statin-switch patients. Patients were treated with rosuvastatin for > or =8 weeks. Primary outcomes were changes in LDL-C levels and proportions of patients achieving their goals (primary prevention, LDL-C < or =130 mg/dL; secondary prevention, LDL-C< or =100 mg/dL). RESULTS: Of 1007 hypercholesterolemic patients, 483 were statin-naive (LDL-C 161+/-40.8 mg/dL) and 524 were statin-switch patients (LDL-C 132.7+/-36.9 mg/dL). In statin-naive patients, rosuvastatin significantly reduced LDL-C, total cholesterol, and triglycerides by 39.9%, 28.8%, and 9.2%, respectively (p<0.001). Eighty-one percent of these patients achieved LDL-C goals. In the statin-switch cohort, LDL-C, total cholesterol, and triglycerides levels were significantly reduced by 24.5%, 16.6%, and 3.8%, respectively (p<0.001). Achievement of target LDL-C levels increased from 29% to 72.9%. There was no significant adverse drug reaction. CONCLUSION: Rosuvastatin was well tolerated and effective in lowering LDL-C in hypercholesterolemic Asian patients. Patients whose LDL-C levels were suboptimal on other statins improved their levels and more achieved LDL-C goals after switching to rosuvastatin.

Risk factors associated with hypertension awareness, treatment, and control in a multi-ethnic Asian population.

OBJECTIVES: To investigate demographic and cardiovascular disease risk factors associated with awareness, treatment and control of hypertension in a multi-ethnic Asian population. METHODS: Participants from four previous cross-sectional studies were invited for a repeat examination (2004--2007). Information of demographic details and cardiovascular disease risk factors was obtained using questionnaire, physical examination and blood tests. Odds ratios and 95% confidence intervals were calculated using multiple logistic regression models. RESULTS: The final number of respondents was 5022 (response rate 49.7%). Although hypertension treatment (84.4% of those aware of hypertension) was high, awareness (51.8% of those having hypertension) and control (27.1% of hypertension on treatment) were low. Reduced awareness and treatment were associated with being younger, never married, and working adults with a higher education level. Low socioeconomic status individuals were more likely to be treated but had poorer control. A similar relationship was found for treatment and control for individuals with coexisting cardiovascular disease risk factors. The use of multiple drug classes was not associated with better control. Diuretic use for treatment of hypertension, as recommended by local and international guidelines, was not common (15.0% of all hypertension medications used). CONCLUSIONS: The awareness, treatment, and control of hypertension in Singapore can be improved. There is a need to improve awareness through education and target screening and treatment in younger, working adults with higher levels of education and higher economic status, as well as Malays. Control of hypertension could be improved among older or diabetic hypertensive individuals.

Risk factor profile and treatment patterns of patients with atherothrombosis in Singapore: insight from the REACH Registry.

INTRODUCTION: Atherothrombosis is the leading cause of cardiovascular mortality. The Reduction of Atherothrombosis for Continued Health (REACH) Registry provided information on atherosclerosis risk factors and treatment. Singapore was one of the 44 participating countries in the REACH Registry. The objective of this study was to determine the atherosclerosis risk factor profile and treatment patterns in Singapore patients enrolled in the REACH Registry. MATERIALS AND METHODS: The REACH Registry is an international prospective observational registry of subjects with or at risk for atherothrombosis. Patients aged 45 years or older with established vascular disease [coronary artery disease (CAD), cerebrovascular disease (CVD), peripheral arterial disease (PAD)] or 3 or more atherosclerosis risk factors were recruited between 2003 and 2004. RESULTS: A total of 881 patients (64.4% male) were recruited in Singapore by 63 physicians. The mean age was 64 +/- 9.8 years (range, 45 to 95). Seven hundred and one (79.6%) patients were symptomatic (CAD 430, CVD 321, PAD 72) while 180 (20.4%) patients had > or =3 risk factors. Approximately 13% of symptomatic patients had symptomatic polyvascular disease. There was a high proportion of diabetes mellitus (57%), hypertension (80.6%) and hypercholesterolemia (80.1%). A substantial proportion of symptomatic patients were current smokers (14.1%). Approximately half of the patients were either overweight or obese [abdominal obesity, 54.3%; body mass index (BMI) 23-27.5, 45.9%; BMI > or =27.5, 23.3%]. Patients were undertreated with antiplatelet agents (71.9% overall; range, 23.9% for > or =3 risk factors to 84.7% for PAD) and statins (76.2% overall; range, 73.6% for PAD to 82.1% for CAD). Risk factors remained suboptimally controlled with a significant proportion of patients with elevated blood pressure (59.4% for > or =3 risk factors and 48.6% for symptomatic patients), elevated cholesterol (40% for > or =3 risk factors and 24.4% for symptomatic patients) and elevated blood glucose (45% for > or =3 risk factors and 19.8% for symptomatic patients). CONCLUSION: Established atherosclerosis risk factors are common in Singapore patients in the REACH Registry; and obesity is a major problem. Most of these risk factors remained suboptimally controlled.

Metabolic syndrome: recent prevalence in East and Southeast Asian populations.

BACKGROUND: The prevalence of the metabolic syndrome among a number of Asian populations as defined by several current criteria has been increasing rapidly and appears to resemble that among Western populations. METHODS: We review 25 surveys of the metabolic syndrome in Asian populations (PR China, Hong Kong, Taiwan, Japan, Philippines, Singapore) that report adequate information published during the last 5 years. RESULTS: Using Asian-adapted definitions of obesity (BMI > or = 25 kg/m(2)) and increased waist circumference (for male > or = 90 cm; for female > or =80 cm) prevalence appears to be between 10 to 30%. Those with the syndrome are more likely to have a history of diabetes and cardiovascular disease. The risk of developing Type 2 diabetes is 10 times higher among middle-aged Japanese men with the metabolic syndrome compared to healthy subjects. In Chinese and Japanese populations, people who have the metabolic syndrome are 3 to 10 times more likely to develop cardiovascular disease. Variance in prevalence estimates of the metabolic syndrome even within the same country result from differences in sampling and possibly from definitions. CONCLUSIONS: The outstanding conclusion from recent surveys across the Asian-Pacific region is that of a consistent increase in the prevalence of the metabolic derangements associated with abdominal adiposity that lead to high risk of morbidity and mortality.

Ankle-brachial index and extent of atherothrombosis in 8891 patients with or at risk of vascular disease: results of the international AGATHA study.

AIMS: AGATHA (a Global Atherothrombosis Assessment) was designed to assess the extent of atherothrombosis and the use of the ankle-brachial index (ABI) in vascular patients. The principal hypotheses were that (1) in diseased patients, a low ABI was related to the number and site of vascular beds affected and (2) in at-risk patients without disease, a low ABI was related to the number of risk factors present. METHODS AND RESULTS: Patients were recruited consecutively by 482 clinicians in 24 countries and the ABI measurement was performed at a single visit. Of 8891 patients recruited, 1792 were defined as at risk and 7099 as with disease. Of the with-disease patients, 65.2% had one arterial bed affected, 27.6% two and 7.1% all three. Abnormal ABI (< or =0.9) was present in 30.9% of at-risk and 40.5% of with-disease patients. A lower ABI was weakly associated with an increasing number of risk factors in at-risk patients (r=-0.056, P=0.02) and with the site and number of arterial beds affected in with-disease patients (P<0.001). CONCLUSION: This large international study confirms that atherothrombotic disease often occurs at more than one site. The ABI is related to the risk factor profile and to the site and extent of atherothrombosis.