High cholesterol and coronary heart disease in younger men: the potential role of stress induced exaggerated blood pressure response

It is well known that by far the strongest association between serum cholesterol levels and the risk of coronary heart disease or related adverse events is found in younger men. The question is - what is different about this age-gender subgroup? It has been suggested that this enhanced risk is seen in younger men because of unique exposure to stress. While stress is known to raise cholesterol levels, the magnitude of the elevation appears insufficient to account for the observed association between cholesterol levels and CHD in young men. An hypothesis is presented which suggests that part and perhaps all of this association is due to the relationship between cholesterol levels and exaggerated blood pressure response to stress, i.e. individuals who exhibit this hyper-response also tend to have significantly elevated cholesterol levels. Given that both stress and an exaggerated blood pressure response to stress are also risk factors for CHD, this could influence the relationship between CHD risk and cholesterol in this age group even if multivariate analysis includes casual blood pressure. This is important since in risk assessment, especially among young men, cholesterol levels play an important role.     

Inter-relationships between arteriosclerotic risk factors: a meta-analysis

This study was performed to clarify the overall inter-relationships between the arteriosclerotic risk factors, including smoking, alcoholic consumption, obesity, serum cholesterol and triglyceride levels, high density lipoprotein, and systolic and diastolic blood pressure using a meta analysis method. The subjects of this study were included in 24 primary studies reported in Korea since 1980, which concerned arteriosclerotic risk factors. The results show that smoking is significantly associated with total cholesterol (R = .04), triglyceride (R = .10) and HDL-cholesterol (R = -.06). Alcohol consumption is also significantly and positively associated with all three serum lipid parameters: cholesterol (R = .04), triglyceride (R = .08) and HDL-cholesterol (R = .10). The effect of smoking and alcohol consumption on cholesterol levels were found to be almost equal. However, smoking has a predominant effect on triglyceride, whereas, alcohol consumption exerts an influence primarily on the HDL-cholesterol level. Obesity was positively correlated with cholesterol (R = .25) and triglyceride (R = .21), however, it was negatively correlated with HDL-cholesterol (R = -.14). It appears that the serum lipid parameter, which shows strongest correlation with obesity, is the total cholesterol level. Obesity also showed a significant correlation with systolic (R = .19) and diastolic blood pressure (R = .13). Blood pressure was also positively correlated with cholesterol (R = .18) and triglyceride (R = .26), however, it correlated negatively with HDL-cholesterol (R = -.23). In conclusion, the overall inter-relationships between the arteriosclerotic risk factors; smoking, alcohol consumption, obesity, serum lipid level and blood pressure were all found to be significant.     

Levels of serum cholesterol, triglyceride, HDL-cholesterol, apoproteins A-I and B, and plasma glucose, and prevalence of diastolic hypertension and cigarette smoking in Papua New Guinea highlanders

Coronary heart disease (CHD) is rare in Papua New Guinea (PNG) highlanders. Fifty-two men and 69 women randomly selected from three rural communities and a low socioeconomic urban community in the Eastern Highlands Province were assessed for hyperlipidemia, diabetes mellitus, diastolic hypertension and cigarette smoking. There was no significant difference between the findings in the rural and urban groups. The mean fasting levels of serum cholesterol, HDL cholesterol and apoproteins A-I and B were significantly lower (p less than 0.001) than those of rural Australians in a comparative study but the serum triglyceride levels were significantly higher in men less than 30 yr and women less than 40 yr of age. There was no significant difference in the serum cholesterol levels in men and women, and the levels of serum cholesterol and triglyceride did not rise with age. The mean fasting levels of plasma glucose were generally lower in PNG subjects and only two (1.7%) had diabetes mellitus. The proportions of highlanders who had diastolic hypertension or who smoked cigarettes were similar to those of Australian populations generally. The low incidence of CHD in PNG highlanders is probably related to the low serum cholesterol and apoprotein B levels, in turn probably related to their basically vegetarian diet and physically active life-style.     

Association of leucine 7 to proline 7 polymorphism in the preproneuropeptide Y with serum lipids in patients with coronary heart disease

Leucine 7 (Leu7) to proline 7 (Pro7) substitution in the neuropeptide Y (NPY) gene has been associated with higher serum total and low-density lipoprotein (LDL) cholesterol levels, particularly in obese subjects. We investigated the frequency of the Pro7 allele and the association of the polymorphism with serum lipid levels in patients with coronary heart disease (CHD). A total of 414 CHD patients (mean age 61 years, range 33-74) participated in the cross-sectional EUROASPIRE study. Of the subjects 39% used lipid-lowering drugs. The frequency of the Pro7 allele in CHD patients (0.082) did not differ from that in control subjects (0.071). The mean (+/-SD) serum total cholesterol concentration was higher in women with the Pro7 allele (7.57 +/- 0.57 mmol/L, n = 8) than in women with the Leu7Leu genotype (6.69 +/- 1.01 mmol/L, n = 69, P = 0.019), when subjects using lipid-lowering medication were excluded. In contrast, serum total cholesterol concentration did not significantly differ between the genotypes in men. The Leu7Pro polymorphism was not associated with serum LDL, high-density lipoprotein (HDL) cholesterol, and triglyceride concentrations. In conclusion, the Pro7 allele in the NPY gene was associated with higher serum total cholesterol concentration only in women with CHD who did not use lipid-lowering drugs.     

Hepatic lipase promoter C-480T polymorphism is associated with serum lipids levels, but not subclinical atherosclerosis: The Cardiovascular Risk in Young Finns Study

The common C‐480T polymorphism (rs1800588) of the hepatic lipase gene (LIPC) has been associated with high‐density lipoprotein (HDL) cholesterol, atherosclerosis, and coronary artery disease. In this study, we examined whether the polymorphism is associated with serum lipid and lipoprotein concentrations, as well as with subclinical atherosclerosis in Young Finns. The participants comprised 2041 men and women (aged 24–39 years) enrolled in the Cardiovascular Risk in Young Finns Study with complete data concerning the rs1800588 polymorphism and serum lipids concentration. All participants underwent an ultrasound examination for brachial artery flow‐mediated vasodilatation (FMD) and carotid artery intima‐media thickness (IMT) measurement. The marker of arterial elasticity, carotid artery compliance (CAC), was also calculated by means of ultrasound and concomitant brachial blood pressure measurements. In all subjects, serum total cholesterol (p < 0.001), HDL cholesterol (p = 0.006), apolipoprotein AI (apoAI, p < 0.001), and triglyceride (p = 0.009) concentrations increased according to rs1800588 genotype in the order CC, CT, and TT. The same order applied only to apoAI after adjustment for age, body mass index, systolic and diastolic blood pressure, smoking, alcohol consumption, physical activity, diabetes, hypertension, contraceptive hormone use in women, and concentrations of glucose, insulin and C‐reactive protein in men and women separately (p = 0.007 and p = 0.003, respectively). The polymorphism was also associated with HDL cholesterol, total cholesterol, and triglyceride levels in women (adjusted p = 0.004, p = 0.007 and 0.02, respectively), but not in men (p was not significant for all). No significant association between the rs1800588 and brachial FMD, carotid IMT, or CAC was found among the entire study population or among women or men separately, with or without adjustment for the above‐mentioned factors. The rs1800588 is associated with serum lipid and apolipoprotein concentrations, especially in women, but does not seem to be a determinant of brachial artery FMD, carotid IMT, or CAC in young healthy adults.     

Psychosocial risk factors for cardiovascular disease in women: The role of social support

Lack of social support is becoming increasingly important as a psychosocial risk factor in the study of coronary heart disease (CHD). There may also be an association between vital exhaustion and lack of social support. Because most research has focused on men, we decided to explore the associations between structural and functional social support and first myocardial infarction (MI) in women. Subjects were 79 women hospitalized with a First MI (mean age 59.3; SD = 9.3) and 90 women hospitalized with an acute surgical event (mean age 57.4: SD = 9 1). MI cases reported more vital exhaustion than did controls (p < ,040), and exhausted women reported less structural (p < .001) and functional support (p < .000). After controlling for age, hypertension, diabetes, menopausal status, smoking, nonanginal pain, and vital exhaustion, multiple logistic regression analysis showed that poor structural support was associated with an increased risk for MI. These results suggest that social support is associated with vital exhaustion, which is a well-known risk factor for CHD. Furthermore, it is suggested that women with only a few confidants are more at risk for MI even after adjustment for well-known risk factors for CHD.     

The relationship of soluble ICAM-1, VCAM-1, P-selectin and E-selectin to cardiovascular disease risk factors in healthy men and women.

BACKGROUND: Clinical studies have shown that elevated serum concentrations of cell adhesion molecules such as inter-cellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1), E-selectin (ESEL) and P-selectin (PSEL) may be independent risk factors for atherosclerosis and cardiovascular disease (CVD). Less is known of the relationship of these inflammatory markers with established CVD risk factors in healthy individuals, particularly women. OBJECTIVE: The aim of this study was to examine cross-sectional relationships between the concentrations of soluble adhesion molecules (sICAM-1, sVCAM-1, sPSEL and sESEL) and smoking behaviour, body composition, blood pressure, serum lipids and physical activity in a large sample of healthy men and women, with special emphasis on interactions between smoking and other CVD risk factors. SUBJECTS: The analysis included 592 healthy white adults aged 18-82 years. RESULTS: There were no sex differences in the concentrations of sICAM-1, sVCAM-1 and sPSEL, but men had higher sESEL levels than women (p < 0.0001). Male and female smokers had higher sICAM-1 and sESEL levels than non-smokers and soluble cell adhesion molecules (CAMs) were correlated with the pack-years of cigarette smoking (r = 0.3-0.4, p < 0.0001, significant in women only). Significant independent associations were found between soluble CAMs and smoking, waist-hip ratio (WHR), blood pressure, high density lipoprotein cholesterol and total cholesterol. Furthermore, significant interaction effects were found in women, such that the relationship between CAMs and lipid concentrations and WHR were stronger in smokers than non-smokers. In conclusion, the concentration of soluble CAMs, particularly sICAM-1 and sESEL, reflect the level of established CVD risk factors in apparently healthy men and women, adding to the evidence that these factors contribute to CVD through their inflammatory effects on the vascular endothelium.     

The relationship of soluble ICAM-1, VCAM-1, P-selectin and E-selectin to cardiovascular disease risk factors in healthy men and women

Background : Clinical studies have shown that elevated serum concentrations of cell adhesion molecules such as inter-cellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1), E-selectin (ESEL) and P-selectin (PSEL) may be independent risk factors for atherosclerosis and cardiovascular disease (CVD). Less is known of the relationship of these inflammatory markers with established CVD risk factors in healthy individuals, particularly women. Objective : The aim of this study was to examine cross-sectional relationships between the concentrations of soluble adhesion molecules (sICAM-1, sVCAM-1, sPSEL and sESEL) and smoking behaviour, body composition, blood pressure, serum lipids and physical activity in a large sample of healthy men and women, with special emphasis on interactions between smoking and other CVD risk factors. Subjects : The analysis included 592 healthy white adults aged 18-82 years. Results : There were no sex differences in the concentrations of sICAM-1, sVCAM-1 and sPSEL, but men had higher sESEL levels than women ( p < 0.0001). Male and female smokers had higher sICAM-1 and sESEL levels than non-smokers and soluble cell adhesion molecules (CAMs) were correlated with the pack-years of cigarette smoking ( r = 0.3 0.4, p < 0.0001, significant in women only). Significant independent associations were found between soluble CAMs and smoking, waist-hip ratio (WHR), blood pressure, high density lipoprotein cholesterol and total cholesterol. Furthermore, significant interaction effects were found in women, such that the relationship between CAMs and lipid concentrations and WHR were stronger in smokers than non-smokers. In conclusion, the concentration of soluble CAMs, particularly sICAM-1 and sESEL, reflect the level of established CVD risk factors in apparently healthy men and women, adding to the evidence that these factors contribute to CVD through their inflammatory effects on the vascular endothelium.     

Associations of HDL phospholipids and paraoxonase activity with coronary heart disease in postmenopausal women

A low high-density lipoprotein-cholesterol (HDL-C) is an established indicator for increased risk of coronary heart disease (CHD). Multiple functional relationships between HDL and CHD have been discussed. We tested the clinical relevance of some of these relationships in a cross-sectional coronary angiography (CA) study of 87 post-menopausal women between 48 and 73 years. In addition to established cardiovascular risk factors we measured concentrations of phosphatidylcholine (PC) and sphingomyelin (SPM) in HDL as indirect markers of cholesterol efflux capacity, the serum activity of the paraoxonase (PON) as a measure of the antioxidative capacity and serum concentrations of insulin/C-peptide and C-reactive protein (CRP) as indirect markers of insulin sensitivity and inflammation, respectively. Upon multivariate analysis of data from 55 women with angiographically assessed CHD differed from 32 women with angiographically excluded CHD, HDL-SPM had the strongest association with the presence of CHD among all HDL-related parameters. It was also the only HDL-related parameter which had a significant and independent correlation with the number of coronary stenoses. As HDL-SPM was previously shown to correlate with cholesterol efflux capacity of plasma, we conclude that reduced cholesterol efflux capacity is an important factor accounting for the inverse association between HDL-cholesterol and CHD.     

Ethnic differences in low-density lipoprotein particle size in hypertensive adults

BackgroundHypertensive African Americans have higher rates of coronary heart disease (CHD) than their non-Hispanic white counterparts, despite having higher high-density lipoprotein cholesterol (HDL-C) levels and lower triglyceride levels.ObjectiveThe goal of the present study was to assess whether low-density lipoprotein (LDL) particle size, a correlate of the above lipid traits and a risk factor for CHD, differs between hypertensive African Americans and whites.MethodsParticipants included 1,177 hypertensive African Americans from Jackson, MS (60 ± 7 years, 72.4% women) and 860 hypertensive whites from Rochester, MN (58 ± 7 years, 56.7% women). LDL particle size was measured by polyacrylamide gradient gel electrophoresis. Within each gender, we assessed whether ethnicity was significantly associated with differences in LDL particle size after adjustment for CHD risk factors (age, total cholesterol, HDL-C, triglycerides, systolic blood pressure, diabetes, history of smoking, body mass index), statin use, and estrogen use (in women), and lifestyle variables (physical activity and alcohol intake).ResultsAlthough HDL-C levels were higher and triglyceride levels lower in African Americans, LDL particle size (adjusted for CHD risk factors) was lower (P < 0.0001) in African-American men and women than in their white counterparts (mean ± SD; men, 267.6 ± 5.2 Å vs 270.2 ± 4.8 Å; women 268.7 ± 5.1 Å vs 271.3 ± 5.1 Å). In both genders, African-American ethnicity was associated with lower LDL particle size after adjustment for CHD risk factors, statin use and estrogen use (in women), as well as physical activity and alcohol intake.ConclusionHypertensive African-American men and women have lower LDL particle size than their white counterparts, despite having higher HDL-C and lower triglycerides.     

Components of hostility as predictors of sudden death and myocardial infarction in the Multiple Risk Factor Intervention Trial

We tested the hypothesis that hostility is associated with increased relative risk (RR) for coronary death and nonfatal myocardial infarction among participants in the prospective Multiple Risk Factor Intervention Trial (MRFIT). Cases (N = 192) were compared with matched controls (N = 384) on a variety of behavioral characteristics associated with the Type A behavior pattern (TABP), including three different but interrelated components of hostility. Logistic regression analyses revealed that only two of the eight TABP attributes analyzed on the overall sample were significant. Only total Potential for Hostility, when dichotomized into "low" and "high" categories, and the antagonistic interpersonal component of hostility (Stylistic Hostility) had positive unadjusted associations with coronary heart disease (CHD) incidence (RR = 1.7, p = 0.003; and RR = 1.5, p = 0.016, respectively). The global TABP and related paralinguistic attributes were not significantly related to CHD incidence. After adjustment for the traditional risk factors of age, serum cholesterol, blood pressure, and cigarette smoking, only dichotomous Potential for Hostility showed a significant relative risk (RR = 1.5, p = 0.032). Ordinal logistic regression revealed a nonsignificant effect.(ABSTRACT TRUNCATED AT 250 WORDS)     

10-year trends in physical activity in the eastern Finnish adult population: relationship to socioeconomic and lifestyle characteristics

In a large, community-based cardiovascular disease prevention study in Eastern Finland, independent random population samples were surveyed in 1972, 1977 and 1982. The leisure-time physical activity (LTPA), occupational physical activity (OPA), and socioeconomic and lifestyle characteristics were assessed. In men and women aged 30-59, the proportion with high LTPA increased from 1972 to 1982 by approximately one half (p less than 0.001), whereas that of high OPA decreased during the same period (p less than 0.001). In both sexes, high overall physical activity fell from 1972 to 1977 (p less than 0.001), but no more from 1977 to 1982. The proportion of entirely sedentary remained stable. Education, income and younger age showed a positive, body mass index, smoking and OPA a graded, negative association with high LTPA in 1972 and 1982. Significant (p less than 0.001) differences in 10-year trends of changes in LTPA were observed: men and women with low education or income increased LTPA more than those with high education and income. Socioeconomic factors, such as income and education, appear to have lost importance as determinants of population-wide exercise, whereas the clustering of low physical activity with overweight and smoking has increased.     

Incidence and risk factors for cardiovascular disease in African Americans with diabetes: the Atherosclerosis Risk in Communities (ARIC) study

To determine the incidence rate of cardiovascular disease (CVD) and its association with conventional and less well-established risk factors in African Americans with diabetes, we studied 741 African Americans aged 45 to 64 years with diabetes, in the Atherosclerosis Risk in Communities (ARIC) study. Risk factors were measured from 1987 to 1989, and incident CVD (n = 143 coronary heart disease (CHD) or stroke events) was ascertained through 1998. The crude incidence rate (per 1000 person-years) of CVD was 22.5 (11.9 for CHD and 12.0 for stroke). After multivariate adjustments, total cholesterol, prevalent hypertension and current smoking were significantly and positively associated with incident CVD among these African Americans with diabetes. Among the non-conventional risk factors, serum creatinine, factor VIII, von Willebrand factor, and white blood cell count were positively and serum albumin negatively and independently associated with CVD incidence. Adjusted relative risks for highest versus lowest tertiles of these risk factors ranged from 1.77 to 2.13. This study confirms that the major risk factors (hypercholesterolemia, hypertension and smoking) are important determinants of CVD in African Americans with diabetes. In addition, several blood markers of hemostasis or inflammatory response and elevated serum creatinine also proved to be CVD risk factors in African Americans with diabetes.     

Relation of serum lipoprotein(a) concentration and apolipoprotein(a) phenotype to coronary heart disease in patients with familial hypercholesterolemia

Familial hypercholesterolemia carries a marked increase in the risk of coronary heart disease (CHD), but there is considerable variation between individuals in susceptibility to CHD. To investigate the possible role of lipoprotein(a) as a risk factor for CHD, we studied the association between serum lipoprotein(a) levels, genetic types of apolipoprotein(a) (which influence lipoprotein(a) levels), and CHD in 115 patients with heterozygous familial hypercholesterolemia. The median lipoprotein(a) level in the 54 patients with CHD was 57 mg per deciliter, which is significantly higher than the corresponding value of 18 mg per deciliter in the 61 patients without CHD. According to discriminant-function analysis, the lipoprotein(a) level was the best discriminator between the two groups (as compared with all other lipid and lipoprotein levels, age, sex, and smoking status). Phenotyping for apolipoprotein(a) was performed in 109 patients. The frequencies of the apolipoprotein(a) phenotypes and alleles differed significantly between the patients with and those without CHD. The allele LpS2, which is associated with high lipoprotein(a) levels, was found more frequently among the patients with CHD (0.33 vs. 0.12). In contrast, the LpS4 allele, which is associated with low lipoprotein(a) levels, was more frequent among those without CHD (0.27 vs. 0.15). We conclude that an elevated level of lipoprotein(a) is a strong risk factor for CHD in patients with familial hypercholesterolemia, and the increase in risk is independent of age, sex, smoking status, and serum levels of total cholesterol, triglyceride, or high-density lipoprotein cholesterol. The higher level of lipoprotein(a) observed in the patients with CHD is the result of genetic influence.     

The association between intraocular pressure and predictors of coronary heart disease risk in Koreans

Elevated intraocular pressure (IOP) is one of the major risk factors for glaucomatous visual field defects. Each individual systemic risk factor of coronary heart disease (CHD) is associated with elevated IOP, although no reports have argued for a correlation between the risk factors for CHD and IOP after a comprehensive or collective analysis. The National Cholesterol Education Program Adult Treatment Panel III presented the Framingham projection, which can predict the risk of CHD quantitatively. We investigated the association between IOP and the Framingham projection in 16,383 Korean subjects. The Framingham projection was applied using the indicated risk factors. The associations between the Framingham projection and IOP and the influences of the risk factors on the IOP were examined. The Framingham projection was correlated with the mean IOP in women (p<0.05). The relationship between IOP and systemic variables other than smoking was significant (p<0.05). The mean IOP was significantly higher in the high-risk CHD group than in the low-risk group based on the Framingham projection (p<0.05). Because an elevated IOP was associated with cardiovascular risk factors, subjects with a high CHD risk based on the Framingham projection need continuous monitoring for IOP to prevent glaucomatous visual field defects.     

Alcohol-related death and associated risk factors in urban middle-aged males

Alcohol-related disorders belong to the spectrum of major non-infectious diseases in Western societies which can be prevented by means that have not yet been fully implemented. Total consecutive mortality in a population of 10353 middle-age males invited to take a part in a preventive medical population program in Malm? was followed up for 3.5-8.5 years (mean 4.5) after the time of invitation and analysed in relation to participation or non-participation and forensic or in-hospital autopsy. Entry characteristics in the 7935 males who attended the screening were compared in order to evaluate risk factor patterns for the major categories of premature death during the follow-up period. Even in the males participating in the screening, alcohol-related deaths (ARD) constituted a major mortality category, comprising 55 of 218 cases, whereas cancer comprised 61 and coronary heart disease (CHD) 50 of the premature deaths in this group. Both in the ARD and CHD categories of male premature mortality, significant and distinctly differential risk factor patterns were found; in CHD for smoking, cholesterol, serum triglycerides and systolic blood pressure, and in ARD for gamma-glutamyltransferase, questionnaire alcoholism screening test and, inversely, serum cholesterol and serum creatinine. In both groups of diseases, these risk factors could be combined into highly predictive multiple logistic risk factor functions. The discriminative power of this instrument was even higher in ARD than in CHD deaths. In consequence, these factors may be applied both as indicators of the ARD risk and as signals and instrument for directed preventive measures in analogy with previously well established and tested methods for the regulation of blood pressure, serum lipids, etc. in the conquest of the cardiovascular diseases.     

Characteristics of young men with clustering risk factors for coronary heart disease: The cardiovascular risk in young finns study

The majority of coronary heart disease (CHD) arises from a population with only moderately elevated risk factor levels. This study addressed the issue of whether clustering of moderately adverse levels of serum low density lipoprotein cholesterol (LDL-C), serum high density lipoprotein cholesterol (HDL-C), and diastolic blood pressure (DBP) was detectable in children and young adults. Significant clustering of these factors was observed in young men (ages 18–24 years) (Observed/Expected [O/E] ratio = 1.5, p = 0.014), whereas in young women or children no clustering greater than due to chance was found. In males, clustering tended to increase with age. Compared to young women, young men had a higher relative intake of dietary fat, and smoked and used alcohol more often. Compared to men without risk factors, the men at risk were significantly more obese, consumed more dietary fat, and smoked more often. The highest degree of clustering was seen in the highest quartile for the subscapular skinfold thickness (O/E ratio = 2.4). In conclusion, high LDL-C, low HDL-C, and high DBP cluster in young adult males. The clear sex difference observed in clustering may be one of the causes for the susceptibility of adult men to CHD. Am. J. Hum. Biol. 9:565–571, 1997. © 1997 Wiley-Liss, Inc.     

Self-involvement and coronary heart disease incidence in the multiple risk factor intervention trial

At intake into a multiple coronary heart disease (CHD) risk factor intervention trial, 3110 individuals were interviewed to assess Type A behavior. After an average of 7 years followup, the 193 individuals who manifested their first CHD event were matched with 384 CHD-free individuals. To assess self-involvement, auditors counted all verbal self-references (I, me, my) and clauses spoken in the audiotaped baseline interviews. Self-references were entered into multiple logistic regression analyses that controlled for age, diastolic blood pressure, cholesterol, cigarette smoking, and Type A behavior. Relative to matched controls, those who incurred CHD spoke more self-references at baseline [p = 0.017; relative risk (RR) = 1.20], but did not self-reference more densely. Relative to matched controls, those who died from CHD spoke more self-references (p = 0.008; RR = 1.62) and self-referenced more densely (p = 0.027; RR = 1.54). Neither total self-references nor self-reference density was predictive of angina pectoris or nonfatal myocardial infarction (MI). However, among those who incurred MI, self-reference frequency was the strongest predictor of mortality among all the measured risk factors (p = 0.01, RR = 2.0). The results suggest that self-involvement is related to CHD incidence.     

Serum cholesterol levels and six-year mortality from stroke in 350,977 men screened for the multiple risk factor intervention trial

We examined the relation between the serum total cholesterol level and the risk of death from stroke during six years of follow-up in 350,977 men, 35 to 57 years of age, who had no history of heart attack and were not currently being treated for diabetes mellitus. The diagnosis of stroke and the type of stroke were obtained from death certificates. Using proportional-hazards regression to control for age, cigarette smoking, diastolic blood pressure, and race or ethnic group, we found that the six-year risk of death from intracranial hemorrhage (International Classification of Diseases, ninth edition [ICD-9], categories 431 and 432) was three times higher in men with serum cholesterol levels under 4.14 mmol per liter (160 mg per deciliter) than in those with higher cholesterol levels (P = 0.05 by omnibus test across five cholesterol levels). On the other hand, a positive association was observed between the serum cholesterol level and death from nonhemorrhagic stroke (P = 0.007). The inverse association of the serum cholesterol level with the risk of death from intracranial hemorrhage was confined to men with diastolic blood pressure greater than or equal to 90 mm Hg, in whom death from intracranial hemorrhage is relatively common. We conclude that there is an inverse relation between the serum cholesterol level and the risk of death from hemorrhagic stroke in middle-aged American men, but that its public health impact is overwhelmed by the positive association of higher serum cholesterol levels with death from nonhemorrhagic stroke and total cardiovascular disease (ICD-9 categories 390 through 459).