Traditional Framingham risk factors fail to fully account for accelerated atherosclerosis in systemic lupus erythematosus

OBJECTIVE: The frequency of coronary heart disease (CHD) and stroke are increased in systemic lupus erythematosus (SLE), but the extent of the increase is uncertain. We sought to determine to what extent the increase could not be explained by common risk factors. METHODS: The participants at two SLE registries were assessed retrospectively for the baseline level of the Framingham study risk factors and for the presence of vascular outcomes: nonfatal myocardial infarction (MI), death due to CHD, overall CHD (nonfatal MI, death due to CHD, angina pectoris, and congestive heart failure due to CHD), and stroke. For each patient, the probability of the given outcome was estimated based on the individual's risk profile and the Framingham multiple logistic regression model, corrected for observed followup. Ninety-five percent confidence intervals (95% CIs) were estimated by bootstrap techniques. RESULTS: Of 296 SLE patients, 33 with a vascular event prior to baseline were excluded. Of the 263 remaining patients, 34 had CHD events (17 nonfatal MIs, 12 CHD deaths) and 16 had strokes over a mean followup period of 8.6 years. After controlling for common risk factors at baseline, the increase in relative risk for these outcomes was 10.1 for nonfatal MI (95% CI 5.8-15.6), 17.0 for death due to CHD (95% CI 8.1-29.7), 7.5 for overall CHD (95% CI 5.1-10.4), and 7.9 for stroke (95% CI 4.0-13.6). CONCLUSION: There is a substantial and statistically significant increase in CHD and stroke in SLE that cannot be fully explained by traditional Framingham risk factors alone.     

Physical activity and other risk factors in male twin-pairs discordant for coronary heart disease

BACKGROUND: Twin-pairs discordant for coronary heart disease (CHD) can be used to examine the possible contribution of genetic and other familial factors to the relationship between CHD risk factors, in particular physical inactivity at leisure, and CHD. METHODS AND RESULTS: In 1975 at baseline, 8205 men aged 25-69 years of the Finnish Twin Cohort without overt CHD responded to a questionnaire. The outcome measures were hospitalization for CHD or death from CHD before age 70 between 1977 to 1995 based on reliable nationwide registries. Among all men, the age-adjusted relative risk of CHD was 0.52 (95% confidence interval (CI) 0.39, 0.71) in men participating in conditioning exercise compared to sedentary men, based on their questionnaire responses. The age, and covariate (body-mass index, smoking, hypertension, diabetes) adjusted-relative risk was 0.68 (CI 0.50, 0.92). Among the twin-pairs discordant for CHD during follow-up (N=311), the odds ratio (OR) of having CHD was 0.54 (CI 0. 27, 1.09) for conditioning exercisers compared to sedentary men. The point estimates from discordant pairs analyses were of the same magnitude as obtained from the analyses of individuals, though statistically not significant due to smaller samples. In contrast, smoking (OR 3.21) and diabetes (OR 10.0) at baseline were also significant predictors of CHD. CONCLUSIONS: By studying twins we were able to examine genetic and other familial selection bias and found further supporting evidence that leisure conditioning physical exercise compared to sedentariness helps prevent CHD in men, but smoking was a stronger risk factor.     

Screening for significant coronary artery disease in high-risk renal transplant candidates

BACKGROUND: Renal transplant candidates are at an increased risk for coronary artery disease (CAD), a strong predictor of cardiovascular events [major adverse coronary events (MACE)]. Coronary angiography is a costly, risky, invasive procedure. We sought to determine clinical predictors of significant CAD (stenosis > or =70%) in high-risk renal transplant candidates. METHODS: Clinical evaluation and coronary angiography were performed in 301 patients (57+/-8 years, 73% men) on hemodialysis for 32 months (median). Patients were followed-up for 22 months (median). Inclusion criteria were diabetes (type 1 or 2), evidence of cardiovascular disease, or age > or =50 years. Risk factors included hypertension (93.7%), overweight/obesity (54.3%), dyslipidemia (44.9%), diabetes (42.1%), and smoking (24.3%). Cardiovascular disease was found as follows: peripheral arterial disease (PAD) (31.2%), angina (28.1%), stroke (12.9%), myocardial infarction (MI) (10.3%), and heart failure (9.3%). RESULTS: Significant CAD was found in 136 individuals (45.2%). Diabetes [odds ratio (OR)=1.82; 95% confidence interval (CI)=1.08-3.07], PAD (OR=2.50; 95% CI=1.44-4.37), and previous MI (OR=7.75; 95% CI=3.03-23.98) were associated with significant CAD. The prevalence of significant CAD increased with the number of clinical predictors from 26% (none) to 100% (all present) (P<0.0001). The incidence of fatal/nonfatal MACE increased two, four, and sixfold in those with diabetes, PAD, or previous MI, respectively (P<0.0001). CONCLUSIONS: In high-risk patients with end-stage renal disease, the prevalence of CAD and the incidence of MACE were high. Significant CAD or cardiovascular complications were not related to the majority of classic risk factors. Patients with diabetes, PAD, or previous MI are at higher risk of CAD, MACE, or both and, thus, must be referred for invasive diagnostic procedures.     

年轻人冠心病危险因素分布及聚集状况

目的　观察年轻人中冠心病危险因素的分布及聚集状况 ,为早期年轻人防治冠心病提供依据。方法　选择年轻冠心病患者 (经冠状动脉造影证实 ,年龄≤ 40岁 ) 1 78例作为疾病组 ,并以年龄匹配的冠状动脉造影正常的年轻人 70例作为对照组 ,分析了传统危险因素 (高血压、高血糖、高血脂、肥胖、吸烟史、家族史 )和新危险因素同型半胱氨酸 (HCY)、脂蛋白 (a)、小而密低密度脂蛋白、C反应蛋白 (CRP)在两组间的变化特点及聚集情况。结果　 (1 )在传统的危险因素中 ,疾病组的甘油三酯(TG)和胆固醇 (TC)水平、吸烟和家族史的比率明显高于对照组 (P <0 0 5) ;在新的危险因素中 ,疾病组的血浆HCY(2 1 66± 1 8 2 2 ) μmol L和CRP(5 78± 6 90 )mg L比对照组的血浆HCY(1 4 94± 8 97)μmol L和CRP(2 87± 2 0 0 )mg L明显增高 (P <0 0 1 ) ,其他危险因素在两组间比较差异无显著性。(2 )疾病组与对照组比较 ,有危险因素者明显增多 (P <0 0 5) ,2种以上新危险因素聚集增加 ,3种新危险因素聚集比较差异有显著性 (P <0 0 5) ,传统危险因素聚集性比较差异无显著性。 (3)logistic回归显示吸烟 (OR值为 2 4,95 %CI:1 31 5～ 4 2 75)、TG(OR值为 1 8,95 %CI:1 2 1 5～ 2 541 )、HCY(OR值为 1 9,95 %CI:1 0 60     

Is diabetes an independent risk factor for mortality after myocardial infarction? The ARIC (Atherosclerosis Risk in Communities) Surveillance Study

Abstract. We investigated the age-, gender- and race-specific 1-year case fatality rates of diabetic and non-diabetic individuals with a myocardial infarction. Data were obtained from the Atherosclerosis Risk in Communities (ARIC) Surveillance Study, which monitors both hospitalized myocardial infarction and coronary heart disease (CHD) deaths in residents aged 35–74 years in four communities in the USA. The study population comprised 3242 hospitalized myocardial infarctions (HMIs) in diabetic subjects and 9826 HMIs in non-diabetic individuals between 1987 and 1997. Age-adjusted and gender- and race-specific odds ratios (OR) for 1-year case fatality comparing diabetic to non-diabetic patients were 2.0 (95% CI, 1.6–2.4) for white men and 1.4 (95% CI, 1.1–1.8) for white women. Further adjustment for severity of HMI, history of previous MI, stroke and hypertension, and therapy variables showed significantly higher case fatality in white diabetic men than in non-diabetic white men (OR=1.5; 95% CI, 1.2–1.9), but no significant association in the other race-gender groups. The age-adjusted odds of out of hospital death was significantly higher among white diabetic men (OR=1.7; 95% CI, 1.2–2.3), white women (OR=2.3; 95% CI, 1.4–3.8), and African-American women (OR=2.9; 95% CI, 1.5–5.9) as compared to their non-diabetic counterparts. In conclusion, diabetes is an independent factor for mortality within one year following a myocardial infarction among white men, and following out-of hospital coronary death in white men and women and in African-American women. It is possible that these differences could be explained, at least in part, by a less than optimal medical management of the high cardiovascular risk profile of these patients after hospital discharge.     

Male pattern baldness and coronary heart disease: the Physicians' Health Study

OBJECTIVE: To examine the association between male pattern baldness and the risk of coronary heart disease (CHD) events. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study among 22,071 US male physicians aged 40 to 84 years enrolled in the Physicians' Health Study. Of these, 19,112 were free of CHD at baseline and completed a questionnaire at the 11-year follow-up concerning their pattern of hair loss at age 45 years. Response options included no hair loss, frontal baldness only, or frontal baldness with mild, moderate, or severe vertex baldness. MAIN OUTCOME MEASURES: Coronary heart disease events defined as nonfatal myocardial infarction (MI), angina pectoris, and/or coronary revascularization. RESULTS: During 11 years of follow-up, we documented 1446 CHD events in this cohort. Compared with men with no hair loss, those with frontal baldness had an age-adjusted relative risk (RR) of CHD of 1.09 (95% confidence interval [CI], 0.94-1.25), while those with mild, moderate, or severe vertex baldness had RRs of 1.23 (95% CI, 1.05-1.43), 1.32 (95% CI, 1.10-1.59), and 1.36 (95% CI, 1.11-1.67), respectively (P for trend, <.001). Multivariate adjustment for age, parental history of MI, height, body mass index (weight in kilograms divided by the square of the height in meters as a continuous variable), smoking, history of hypertension, diabetes, high cholesterol level, physical activity, and alcohol intake did not materially alter these associations. Results were similar when nonfatal MI, angina, and coronary revascularization were examined separately, and when events were analyzed among men older and younger than 55 years at baseline. Vertex baldness was more strongly associated with CHD risk among men with hypertension (multivariate RR, 1.79; 95% CI, 1.31-2.44) or high cholesterol levels (multivariate RR, 2.78; 95% CI, 1.09-7.12). CONCLUSION: Vertex pattern baldness appears to be a marker for increased risk of CHD events, especially among men with hypertension or high cholesterol levels.     

Hyperhomocystinemia: a risk factor or a consequence of coronary heart disease?

BACKGROUND: Mild hyperhomocystinemia has been suggested as an indicator of an increased risk of cardiovascular disease. OBJECTIVE: To examine whether serum homocysteine concentration is a predictor of coronary heart disease (CHD) events. METHODS: A case-control study, nested in a population-based cohort study was used. During a follow-up of 13 years, 166 major coronary events (death from CHD or nonfatal myocardial infarction) occurred in men with evidence of heart disease at baseline and 272 events in men without a history of heart disease. Two controls per case were selected by individual matching. RESULTS: Among men with known heart disease at baseline, the relative risk (95% confidence interval) of CHD events adjusted for age, smoking, hypertension, diabetes mellitus, serum cholesterol level, body mass index, and alcohol consumption was 2.23 (95% confidence interval, 1.03-4.85) in the highest serum homocysteine quintile compared with the lowest quintile. Among the men free of heart disease at baseline, the corresponding relative risk was 0.90 (95% confidence interval, 0.51-1.60). CONCLUSIONS: This prospective study does not support the hypothesis that a high concentration of serum homocysteine is a risk factor for coronary events in a population free of heart disease. However, it does suggest that mild hyperhomocystinemia predicts secondary coronary events in men with heart disease, possibly as a consequence of atherosclerotic changes.     

Relation between hypertension and cardiovascular events--implications for coronary prevention.

OBJECTIVE: To study the relation between hypertension and cardiovascular events--stroke, myocardial infarction (MI), heart failure (HF), and chronic renal failure (CRF)--and to define implications for cardiovascular disease prevention. DESIGN: Cross-sectional study, in two stages, but with retrospective information about major cardiovascular events. SETTING: Primary care health centers (Lisbon Regional Health Administration). MATERIAL AND METHODS: Participants: 3228 patients, 1100 male (439 aged up to 60 years and 661 aged 60 years) and 2128 females (860 aged up to 60 years and 1268 aged 60 years). The study covered stroke, myocardial infarction, heart failure, chronic renal failure with co-variables of age, gender, body mass index (BMI), blood pressure, heart rate, antihypertensives, diabetes, total cholesterol, dyslipidemic therapy, and smoking. The group without hypertension (normotensives) and hypertensives--treated with antihypertensives and/or with systolic/diastolic blood pressure > or = 140/90 mmHg (n = 2169)--were compared, using logistic regression, to identify nonfatal cardiovascular complications associated with hypertension. Forward conditional logistic regression was used to test the multivariate models. The level of significance was taken to be 5%. The statistical packages Stata and SPSS were used. RESULTS: The analysis included 2839 cases (389 missing). The absolute frequencies of categorical variables were: smoking (n = 343); stroke (n = 150); myocardial infarction (n = 90); heart failure (n = 174); renal failure (n = 34); hypercholesterolemia (n = 864); diabetes (n = 375); male gender (n = 976) and female gender (n = 1863). The regression equation included the following factors: age (p < 0.001; OR = 1.068 and 95% CI 1061-1.075); body weight (p = 0.001; OR = 1.020 and 95% CI 1.008-1.032); stroke (p = 0.007; OR = 2.523 and 95% CI 1.286-4.951); HF (p = 0.013; OR = 2.449 and 95% CI 1.205-4.979); diabetes (p < 0.001; OR = 1.894 and 95% CI 1.328-2.701); hypercholesterolemia (p < 0.001; OR = 1.693 and 95% CI 1.350-2.123); and BMI (p < 0.001; OR = 1.006 and 95% CI 1.003-1.010). CONCLUSIONS: Nonfatal stroke was associated with hypertension, as was heart failure, but neither nonfatal myocardial infarction nor chronic renal failure were. Control of hypertension is therefore expected to be more efficacious in reducing cerebrovascular events than those caused by coronary heart disease.     

Cardiovascular disease in US firefighters: a systematic review

Cardiovascular disease (CVD) is the leading cause of on-duty death among firefighters (45% of on-duty fatalities) and a major cause of morbidity. CVD in the fire service also has adverse public safety implications as well as significant cost impacts on government agencies. Over the last decade, our understanding of CVD among firefighters has significantly improved and provides insight into potential preventive strategies. The physiology of cardiovascular arousal and other changes that occur in association with acute firefighting activities have been well-characterized. However, despite the strenuous nature of emergency duty, firefighters' prevalence of low fitness, obesity, and other CVD risk factors are high. Unique statistical approaches have documented that on-duty CVD events do not occur at random in the fire service. They are more frequent at certain times of day, certain periods of the year, and are overwhelmingly more frequent during strenuous duties compared with nonemergency situations. Moreover, as expected on-duty CVD events occur almost exclusively among susceptible firefighters with underlying CVD. These findings suggest that preventive measures with proven benefits be applied aggressively to firefighters. Furthermore, all fire departments should have entry-level medical evaluations, institute periodic medical and fitness evaluations, and require rigorous return to work evaluations after any significant illness. Finally, on the basis of the overwhelming evidence supporting markedly higher relative risks of on-duty death and disability among firefighters with established coronary heart disease, most firefighters with clinically significant coronary heart disease should be restricted from participating in strenuous emergency duties.     

Increased unrecognized coronary heart disease and sudden deaths in rheumatoid arthritis: a population-based cohort study

OBJECTIVE: To examine the risk of clinical coronary heart disease (CHD) in patients with rheumatoid arthritis (RA) compared with age- and sex-matched non-RA subjects, and to determine whether RA is a risk factor for CHD after accounting for traditional CHD risk factors. METHODS: We assembled a population-based incidence cohort of 603 Rochester, Minnesota residents ages >or=18 years who first fulfilled the American College of Rheumatology (ACR) 1987 criteria for RA between January 1, 1955 and January 1, 1995, and 603 age- and sex-matched non-RA subjects. All subjects were followed up through their complete inpatient and outpatient medical records, beginning at age 18 years until death, migration, or January 1, 2001. Data were collected on CHD events and traditional CHD risk factors (diabetes mellitus, hypertension, dyslipidemia, body mass index, smoking) using established diagnostic criteria. CHD events included hospitalized myocardial infarction (MI), unrecognized MI, coronary revascularization procedures, angina pectoris, and sudden CHD deaths. Conditional logistic regression and Cox regression models were used to estimate the risk of CHD associated with RA, both prior to and following RA diagnosis, after adjusting for CHD risk factors. RESULTS: During the 2-year period immediately prior to fulfillment of the ACR criteria, RA patients were significantly more likely to have been hospitalized for acute MI (odds ratio [OR] 3.17, 95% confidence interval [95% CI] 1.16-8.68) or to have experienced unrecognized MIs (OR 5.86, 95% CI 1.29-26.64), and less likely to have a history of angina pectoris (OR 0.58, 95% CI 0.34-0.99) compared with non-RA subjects. After the RA incidence date, RA patients were twice as likely to experience unrecognized MIs (hazard ratio [HR] 2.13, 95% CI 1.13-4.03) and sudden deaths (HR 1.94, 95% CI 1.06-3.55) and less likely to undergo coronary artery bypass grafting (HR 0.36, 95% CI 0.16-0.80) compared with non-RA subjects. Adjustment for the CHD risk factors did not substantially change the risk estimates. CONCLUSION: Patients with RA have a significantly higher risk of CHD when compared with non-RA subjects. RA patients are less likely to report symptoms of angina and more likely to experience unrecognized MI and sudden cardiac death. The risk of CHD in RA patients precedes the ACR criteria-based diagnosis of RA, and the risk cannot be explained by an increased incidence of traditional CHD risk factors in RA patients.     

Relative importance of atherosclerotic risk factors for coronary heart disease in Taiwan.

BACKGROUND: The relative importance of atherosclerotic risk factors, such as hypertension, dyslipidemia, diabetes and smoking, was associated with cardiovascular events and varied among different ethnic groups. For a population with relatively low coronary heart disease (CHD) such as Asian-Pacific countries, it is crucial to differentiate the roles of these risk factors. METHODS: We examined the relative importance of various risk factors for CHD in a community-based cohort in Taiwan, consisting of 3602 adults aged 35 and older with a median follow-up time of 9.0 years since 1990. Regular death certificate verification and medical record reviews were performed in the follow-up activities. RESULTS: There were 85 cases defined as CHD. In the Cox proportional hazard analysis, men were at higher risk than women [hazard risk (HR)=2.22, 95% confidence interval (CI)=1.39-3.56]. Hypertension was the most common risk factor for CHD. Dyslipidemia, especially lowered high-density lipoprotein cholesterol, also played an important role (HR=2.09, 95% CI=1.33-3.29) in CHD events. Hypertension had a greater influence in males (HR=6.08, P<0.001) than in females (HR=2.80, P<0.001). No independent association was found for smoking or body mass index in cardiovascular events. CONCLUSION: This study found that in a community-based cohort, hypertension, and dyslipidemia attribute an important role to cardiovascular events.     

Coronary heart disease death,nonfatal acute myocardial infarction and other clinical outcomes in the multiple risk factor intervention trial

The Multiple Risk Factor Intervention Trial was a randomized clinical study to test whether a special intervention (SI) program aimed at reducing serum cholesterol levels, blood pressure and cigarette smoking would prevent coronary heart disease (CHD) in middle-aged men. The main endpoint reported here is the percentage of participants experiencing first major CHD events (either nonfatal acute myocardial infarction [AMI] or CHD death) during 7 years of follow-up. This outcome was slightly less frequent in the 6,428 SI men than in the 6,438 men assigned to their usual source of care (UC). However, the relative difference—either 1% (95% confidence interval −17% to 16%) or 8% (95% confidence interval −5% to 20%), depending on how AMI was classified—was not statistically significant.Regression analyses within the SI and UC groups suggested that the cholesterol and cigarette smoking interventions reduced the number of first major CHD events: the associations between lowering the levels of these 2 factors and reductions in CHD rates were significant (p < 0.001) and of the anticipated magnitude. A similar analysis of antihypertensive treatment in the SI group revealed no favorable association between lowering blood pressure and CHD rate, and other subgroup comparisons suggested that a mixture of beneficial and adverse effects may underlie this finding. Thus, the nonsignificant overall UC/SI contrast in CHD rates may reflect a combination of the expected beneficial effects of the cholesterol and smoking interventions with unexpected heterogeneous effects of the antihypertensive intervention.Seven of 8 other prespecified cardiovascular endpoihts occurred less frequently among SI than among UC men, the difference being nominally significant (p < 0.05) for angina pectoris, congestive heart failure and peripheral arterial disease.     

Lack of association between prior infection with Chlamydia pneumoniae and acute or chronic coronary artery disease

BACKGROUND: Higher than normal serologic titers and the detection of bacteria within atheroma have suggested an association between Chlamydia pneumoniae (C. pneumoniae) infection and coronary heart disease (CHD), but the relationship has not been well established. HYPOTHESIS: The study was designed to establish a lack of relationship between chronic C. pneumoniae infection and CHD. METHODS: Chlamydia-specific IgG-antibody was assayed using an indirect immunofluorescence test in the serum of 159 patients with severe arterial disease and 203 patients with a heart valve prostheses and no demonstrable CHD. Fatal and nonfatal vascular events and systemic thromboembolism were recorded over a 2-year period. RESULTS: In the arterial group 107 patients (67.3%) and in the valvular group 120/203 (59.1%) were positive for C. pneumoniae antibody. The number of patients with fatal or nonfatal vascular events (double end point) in the arterial and valvular groups was 23 and 2, respectively (p < .0001). Triple end points (fatal plus nonfatal vascular events plus thromboembolism) were also more frequent in the arterial group (p < 0.002). The prevalence of chlamydia antibody positivity was the same in the arterial and valvular groups, and the occurrence of clinical events was also the same for chlamydia-positive (227 patients) as for chlamydia-negative (135 patients). After adjustment for confounding variables, only arterial disease was a predictive factor for double (OR 17.0; 95% CI 3.94-73.3) or triple (OR 3.12; 95% CI 1.56-6.25) end points. CONCLUSION: We find C. pneumoniae chronic infection not to be an independent risk factor for acute or chronic arterial disease.     

Prevalence and risk factor correlates of elevated C-reactive protein in an adult Australian population

Measurement of the inflammatory biomarker C-reactive protein (CRP) is advocated for coronary heart disease risk assessment. The distribution and correlates of CRP in the general population should be known before it is used in clinical practice. CRP was measured in 1,761 men and 2,248 women aged 25 to 84 years who attended the 1994/1995 Busselton Health Survey. Prevalences of increased CRP >3 mg/L for age groups 25 to 39, 40 to 59, and 60 to 84 years were 15.7%, 20.6%, and 38.7%, respectively, in men and 21.2%, 22.1%, and 33.7%, respectively, in women not on hormone therapy. Logistic regression analysis identified independent predictors of increased CRP in men as obesity (odds ratio [OR] 3.5, 95% confidence interval [CI] 2.4 to 5.0), smoking (OR 3.1, 95% CI 2.1 to 4.5), hypertension (OR 1.6, 95% CI 1.1 to 2.3), and low high-density lipoprotein cholesterol (OR 1.4, 95% CI 1.0 to 1.8). In women, predictors were obesity (OR 7.8, 95% CI 5.8 to 10.6), hypertension (OR 1.4, 95% CI 1.0 to 1.9), high triglycerides (OR 1.6, 95% CI 1.1 to 2.4), vigorous exercise (OR 0.7, 95% CI 0.5 to 0.9), oral contraceptive use (OR 4.6, 95% CI 3.3 to 6.5), and hormone replacement therapy (OR 2.8, 95% CI 1.9 to 4.0). Overall, risks of increased CRP attributable to the presence of an abnormal or borderline coronary heart disease risk factor were 59% for men and 64% for women. In conclusion, despite gender-related differences in cardiovascular risk, increased CRP occurred commonly in men and women. Because increased CRP was largely attributable to conventional coronary heart disease risk factors, measurement of CRP may have limited utility for risk screening and primary prevention.     

Identifying high risk in adults with congenital heart disease and atrial arrhythmias

Atrial arrhythmias are associated with an increased mortality risk in adults with congenital heart disease (CHD). However, little is known about risk stratification in the specific group of adult patients with CHD and atrial arrhythmias. We sought to identify predictors of mortality in adult with CHD and atrial arrhythmias and to establish a risk score. The study involved 378 adult patients with CHD (mean age 39 ± 13 years) and atrial arrhythmias who had serial follow-up in a tertiary referral center from 1999 through 2009. During a median follow-up of 5.2 years, there were 40 deaths (11%). Overall mortality rate was 2.0% per patient-year. Common modes of death included heart failure-related death (35%), sudden cardiac death (20%), and perioperative death (18%). Independent predictors of mortality were poor functional class (hazard ratio 3.69, 95% confidence interval [CI] 1.69 to 8.03, p = 0.001), single-ventricle physiology (hazard ratio 3.33, 95% CI 1.51 to 7.35, p = 0.003), pulmonary hypertension (hazard ratio 2.96, 95% CI 1.41 to 6.19, p = 0.004), and valvular heart disease (hazard ratio 2.73, 95% CI 1.33 to 5.59, p = 0.006). A risk score was constructed using these predictors in which patients were assigned 1 point for the presence of each risk factor. Mortality rates in the low-risk (no risk factor), moderate-risk (1 risk factor), and high-risk (>1 risk factor) groups were 0.5%, 1.9%, and 6.5% per patient-year, respectively (log-rank p <0.001). In conclusion, in adult with CHD and atrial arrhythmias specific clinical variables identify patients at high risk for death. Importantly, the absence of any of these risk factors is associated with an excellent survival despite the presence of atrial arrhythmias.     

Fatty liver and uric acid levels predict incident coronary heart disease but not stroke among atomic bomb survivors in Nagasaki.

Relationships between fatty liver and coronary heart disease (CHD) and stroke risk remain ill defined. We investigated whether fatty liver is a predictor of CHD and stroke risk. Until December 2000 we followed 2,024 atomic bomb survivors (775 men: 62.0 +/- 9.9 years old; 1,249 women: 63.2 +/- 8.4 years old) who had basic examinations between November 1990 and October 1992 for clinical and laboratory CHD risk factors and fatty liver and who were initially free of CHD and stroke. Forty-nine cases of CHD and 84 cases of stroke were observed. At the time of the baseline examinations, significant clinical associations were found between fatty liver and obesity (p<0.001), hypertension (p<0.001), dyslipidemia (p<0.001), and glucose intolerance (p<0.001). A slight but nonsignificant association was found between fatty liver and hyperuricemia (p=0.07) as well. By using multiple Cox regression analyses, age (relative risk [RR] 1.05, 95% confidence interval [CI] 1.01-1.08), smoking (RR 2.20, 95% CI 1.02-4.74), hyperuricemia (RR 2.30, 95% CI 1.08-4.89), and fatty liver (RR 2.53, 95% CI 1.06-6.06) were shown to be significant predictors of CHD, whereas age (RR 1.08, 95% CI 1.06-1.10), smoking (RR 2.06, 95% CI 1.14-3.72), and hypertension (RR 2.14, 95% CI 1.38-3.30) predicted stroke risk. Fatty liver, which clusters clinical and laboratory CHD risk factors, is an independent predictor of CHD, but not of stroke. Fatty liver should be followed as a feature of metabolic syndrome, with the aim of preventing CHD.     

A possible protective effect of nut consumption on risk of coronary heart disease. The Adventist Health Study.

BACKGROUND--Although dietary factors are suspected to be important determinants of coronary heart disease (CHD) risk, the direct evidence is relatively sparse. METHODS--The Adventist Health Study is a prospective cohort investigation of 31,208 non-Hispanic white California Seventh-Day Adventists. Extensive dietary information was obtained at baseline, along with the values of traditional coronary risk factors. These were related to risk of definite fatal CHD or definite nonfatal myocardial infarction. RESULTS--Subjects who consumed nuts frequently (more than four times per week) experienced substantially fewer definite fatal CHD events (relative risk, 0.52; 95% confidence interval [CI], 0.36 to 0.76) and definite nonfatal myocardial infarctions (relative risk, 0.49; 95% CI, 0.28 to 0.85), when compared with those who consumed nuts less than once per week. These findings persisted on covariate adjustment and were seen in almost all of 16 different subgroups of the population. Subjects who usually consumed whole wheat bread also experienced lower rates of definite nonfatal myocardial infarction (relative risk, 0.56; 95% CI, 0.35 to 0.89) and definite fatal CHD (relative risk, 0.89; 95% CI, 0.60 to 1.33) when compared with those who usually ate white bread. Men who ate beef at least three times each week had a higher risk of definite fatal CHD (relative risk, 2.31; 95% CI, 1.11 to 4.78), but this effect was not seen in women or for the nonfatal myocardial infarction end point. CONCLUSION--Our data strongly suggest that the frequent consumption of nuts may protect against risk of CHD events. The favorable fatty acid profile of many nuts is one possible explanation for such an effect.     

Association of serum apolipoprotein A-I (but not high-density lipoprotein cholesterol) with healed myocardial infarction in men independent of serum insulin and C-peptide

Low serum levels of high-density lipoprotein (HDL) cholesterol or apolipoprotein A-I and high serum levels of insulin increase the risk of coronary heart disease (CHD) and can indicate insulin resistance. We tested the strength, independence, and interactions of associations between HDL cholesterol (or apolipoprotein A-I), insulin (or C-peptide), glucose, and CHD in 95 male nondiabetic patients with CHD who were <60 years old, in 92 probands from the PROCAM study, and in 61 non-cardiologic patients; all subjects were matched by age, body mass index, and smoking habits. Systemic hypertension (odds radio [OR] 2.8, 95% confidence intervals [CI] 1.6 to 4.8), high serum levels of glucose (OR 2.3, 95% CI 1.6 to 4.8), insulin (OR 2.1, 95% CI 1.3 to 3.6), and C-peptide (OR 4.1, 95% CI 2.2 to 7.5) as well as low serum levels of HDL cholesterol (OR 2.0, 95% CI 1.1 to 3.5) or apolipoprotein A-I (OR 3.9, 95% CI 2.1 to 7.1) had significant associations with CHD. At multivariate analysis, systolic blood pressure, glucose, apolipoprotein A-I, and C-peptide, but not HDL cholesterol and insulin, had consistent independent associations with CHD. Thus, the combined measurement of apolipoprotein A-I and C-peptide may improve the identification of nondiabetic patients at increased risk for CHD.     

Cardiovascular and disease-related predictors of depression in systemic lupus erythematosus

Objective

Depression and cardiovascular disease are common and debilitating comorbidities associated with systemic lupus erythematosus (SLE). In this study, history of cardiovascular events, cardiovascular risk factors, and SLE disease‐related factors were evaluated as longitudinal predictors of depression in a large cohort of patients with SLE.

Methods

Data were derived from 663 adult participants in the 2004–2008 Lupus Outcomes Study, who were followed for up to 5 annual interviews. Multivariate logistic regression analyses using generalized estimating equations were used to determine predictors of the development of increased depressive symptom severity over a 12‐month period (Center for Epidemiologic Studies Depression Scale [CES‐D] score of 23 or greater), yielding 2,224 paired observations. Predictors included sociodemographics, traditional cardiovascular risk factors (reported presence of heart disease, history of stroke or myocardial infarction, hypertension, hypercholesterolemia, diabetes mellitus, obesity, smoking status, and family history), and SLE‐specific risk factors (glucocorticoid use, renal involvement, disease duration, and disease activity).

Results

The annual incidence of depression was 12% in this cohort. Multivariate predictors of new‐onset depression included younger age (ages 20–39 years: odds ratio [OR] 2.3, 95% confidence interval [95% CI] 1.3–3.9; ages 40–59 years: OR 1.8, 95% CI 1.1–2.7), Hispanic/Latino ethnicity (OR 1.8, 95% CI 1.2–2.8), having some college education (OR 1.8, 95% CI 1.1–3.0), baseline CES‐D score (OR per point 1.1, 95% CI 1.1–1.2), presence of diabetes mellitus (OR 1.8, 95% CI 1.1–2.8), and baseline SLE disease activity (OR 1.2, 95% CI 1.1–1.4).

Conclusion

These results suggest that, in addition to known sociodemographic factors, the presence of diabetes mellitus and SLE disease activity may play a role in the development of depression in SLE.     

Lipoprotein particles, insulin, adiponectin, C-reactive protein and risk of coronary heart disease among men with metabolic syndrome

We tested the hypotheses whether nuclear magnetic resonance (NMR) determined lipoprotein particles, insulin and adiponectin, and C-reactive protein (CRP) and white blood cell (WBC) count as markers of inflammation predicted risk of coronary heart disease (CHD) death among 428 men age 35-57 years with metabolic syndrome (MetSyn) in a matched case control study within the multiple risk factor intervention trial. Blood samples collected at entry into the study and stored at -60 degrees C were obtained from central storage for blood analyte analysis. Two hundred and fourteen men with MetSyn who died of CHD were matched with 214 men with MetSyn who did not die of CHD during 18 years of follow-up. Cases were matched to controls on age, study group, number of factors present in the MetSyn, and presence or absence of a nonfatal CVD event during the trial. Mortality follow-up was determined using the National Death Index. Higher levels of high density lipoprotein particles (HDL-P), especially medium-sized HDL-P [hazard ratio (95% confidence interval) 0.45 (0.25-0.83, P<0.01), quartile 1 as compared to quartile 4], were associated with lower risk of CHD death. Low density lipoprotein (LDL) particles were not associated with increased risk of CHD. Elevated LDL cholesterol (LDL-C), smoking and WBC count were, but levels of adiponectin, insulin and CRP were not significantly related to CHD death. In multivariate models adjusting for smoking and LDL-C, medium HDL-P and WBC count remained independent predictors of CHD death. Number of HDL particles, especially medium-sized HDL particles and WBC count were independent predictors of CHD death among men with MetSyn.