Predictors of subsequent coronary events,stroke, and death among survivors of first hospitalized myocardial infarction

We identified predictors of prognosis among n = 2,677 health maintenance organization enrollees 30 to 79 years old who survived a first hospitalized myocardial infarction (MI) during 1986-1996 (mean follow-up 3.4 years). Independent risk factors for reinfarction/fatal coronary heart disease (CHD) (incidence = 49.0/1,000 person-years, 445 events) were age, diabetes, chronic congestive heart failure (CHF), angina, high body mass index (BMI), low diastolic blood pressure (DBP), high serum creatinine, and low/high-density lipoprotein (HDL) cholesterol. Independent risk factors for stroke (incidence = 13.0/1,000 person-years, 124 events) were age, diabetes, CHF, high DBP, and high creatinine. Independent predictors of death (incidence = 44.2/1,000 person-years, 431 events) were age, diabetes, CHF, continued smoking after MI, low DBP, high pulse rate, high creatinine, and low HDL cholesterol, while BMI had a significant U-shaped association with death (elevated risk at low and high BMI). The occurrence of study end points did not differ significantly between men and women after adjustment for other risk factors and use of preventive medical therapies, although men tended to have higher rates of reinfarction/CHD than women among older subjects. In summary, we demonstrated that the major cardiovascular risk factors age, diabetes, CHF, smoking, and dyslipidemia are important prognostic factors in the years after nonfatal MI. Elevated BMI was associated with increased risk of reinfarction/CHD and death and elevated DBP with increased risk of stroke, but we also observed high mortality among those with low BMI and high risk of recurrent coronary disease and death among those with low DBP. Finally, high creatinine was a strong, independent predictor of a variety of adverse outcomes after first MI.     

Sex differences in preinfarction characteristics and longterm survival among patients with myocardial infarction

The prevalence of primary risk factors, previous medical history, and physical activity were assessed among 262 women and 1259 men who suffered a first nonfatal myocardial infarction between 1968 and 1977 in G?teborg, Sweden. The probability of suffering a myocardial infarction based on the conventional factors cholesterol level, systolic blood pressure and smoking habits was estimated in both sexes by means of a multiple risk function. Comparisons between sexes were made with age alone and age and estimated primary risk as confounders. Survival rate and reinfarction rate were calculated for a 5-year period of follow-up. Women with infarctions had higher serum cholesterol levels (p less than 0.001) and higher blood pressure values (p less than 0.001) but were less often smokers than men (p less than 0.001). The female patients also reported chest pain and dyspnea on exertion, and low physical activity both at work and during leisure time significantly more often than men; these differences remained after controlling for estimated primary risk. An overrepresentation of hypertension and diabetes prior to myocardial infarction was found among women below 45 years of age compared with men. A high frequency of women in this age group was also on sick leave or disability pension at onset of myocardial infarction, suggesting that mainly women with several risk factors including socioeconomic factors suffer an infarction at this age. No similar and consistent differences were found between women and men of older ages. The cumulative 5-year survival rate was 80% in women and 81% in men. Below age 45 the survival rate was lower among women than men (p less than 0.01). No sex difference was found in the recurrence rate of nonfatal reinfarctions. This indicates that once women have suffered a myocardial infarction they are exposed to at least as high a risk as men.     

Blood pressure and cardiovascular morbidity and mortality in a Dutch population: the Nijmegen cohort study

BACKGROUND. The objective was to determine the influence of systolic blood pressure and diastolic blood pressure on the development of coronary heart disease over an 18-year period in a Dutch general practice population. METHODS. The Nijmegen Cohort Study is a prospective cohort study with an 18-year follow-up. In 1977 systolic blood pressure, diastolic blood pressure, and other cardiovascular risk factors were measured in 7,092 Caucasians, men and women. The screening took place in six general practices, participating in a university registration network. Cardiovascular disease and all mortality was registrated during the 1977-1995 period. A Cox proportional hazard model was performed separately for men and women with the first onset of a coronary heart disease as the outcome variable. Age, smoking, serum cholesterol, blood pressure, and socioeconomic class were included as independent variables. RESULTS. During the 18-year follow-up period, 205 men and 63 women suffered a nonfatal myocardial infarction. During this time, 205 deaths were identified, of which 54 were cardiovascular. Of all deaths, 139 were noncardiovascular, of which 10% were due to accident or suicide, while in 12 participants the cause of death was uncertain. The analysis indicated that both the systolic and the diastolic blood pressure were independently associated with the likelihood for developing coronary heart disease, as were the other risk factors. For coronary heart disease, the significant risk ratios for the systolic blood pressure were 1.6 for men and 2.1 for women. For the diastolic blood pressure a risk ratio was found of 1.4 for men and 2.0 for women. CONCLUSION. A significant relation between blood pressure and coronary heart disease was demonstrated. As mean blood pressures, cholesterol levels, smoking habits, and socioeconomic class in this cohort did not differ from other figures in The Netherlands, extrapolation of the results to the Dutch population is possible.     

Diabetes and coronary heart disease risk in Mexican Americans.

Mexican Americans have a high prevalence of diabetes relative to non-Hispanic whites, but paradoxically experience a lower prevalence of myocardial infarction and lower cardiovascular mortality (at least in men). To determine whether Mexican Americans might be more resistant to the atherogenic effects of diabetes than non-Hispanic whites, we examined the associations between diabetes and myocardial infarction and selected coronary heart disease (CHD) risk factors in these two ethnic groups. The study population consisted of 5149 Mexican Americans and non-Hispanic whites who were 25 to 64 years old and recruited from the San Antonio Heart Study, a population-based study of cardiovascular risk factors and diabetes conducted between 1979 and 1988. Diabetic men were more than twice as likely to have an electrocardiography (ECG)-documented myocardial infarction than were nondiabetic men, while diabetic women were more than three times as likely to have a myocardial infarction than were nondiabetic women. In both sexes the association between myocardial infarction and diabetes was nearly identical between the two ethnic groups. In both ethnic groups diabetes was also more strongly associated with conventional CHD risk factors (e.g., triglycerides, systolic blood pressure, and high-density-lipoprotein cholesterol) in women than in men. Furthermore, these associations were at least as strong, if not stronger, in Mexican Americans as in non-Hispanic whites. Thus, these data provide no evidence to suggest that Mexican Americans are resistant to the lipid-altering effects of diabetes. We conclude that the protective effect against CHD conferred by Mexican American ethnicity may be obscured in part by the high prevalence of diabetes in this ethnic group.     

Myocardial infarction and coronary death among women: psychosocial predictors from a 20-year follow-up of women in the Framingham Study.

This study investigates the relation of psychosocial variables to the 20-year incidence of myocardial infarction or coronary death among women in the Framingham Study. In 1965-1967, a psychosocial interview was given along with the collection of other coronary risk factor data. This study includes 749 women aged 45-64 years who were free of coronary disease at this baseline examination. Demographic variables, psychosocial scales (such as tension and reactions of anger), and individual interview items (such as attitudes toward children, money, and religion) were measured. When age, systolic blood pressure, the ratio of serum total cholesterol to high-density lipoprotein cholesterol, diabetes, cigarette smoking, and body mass index were controlled for in multivariate proportional hazards models, the predictors of the 20-year incidence of myocardial infarction or coronary death were as follows: among employed women, perceived financial status only; among homemakers, symptoms of tension and anxiety, being lonely during the day, difficulty falling asleep, infrequent vacations, housework affecting health, and believing one is prone to heart disease (p less than 0.05 for all variables); and among both groups of women combined, low educational level, tension, and lack of vacations. These results are discussed in relation to previous findings from the Framingham Study.     

Prediction of stroke, coronary heart disease, cardiovascular disease, cancer, and total death based on results of annual health checkups

OBJECTIVE: We aimed to predict mortality rate from the findings of annual health checkups for men and women. METHOD: The subjects were 31,053 men and 61,224 women who were living in Ibaraki prefecture (Japan), aged 40 to 79 years, without history of any stroke and coronary heart disease, and who participated in annual health checkups in 1993. They were followed until the end of 2001, with a systemic review of resident registration and death certificates. The Cox's proportional hazards model with step-down procedure was used to estimate predictive model. RESULTS: During the 8.0 years follow-up, there were 5260 deaths (710 from stroke, 389 from coronary heart disease and 2,322 from cancer). The predictive factors for all causes were advanced age, high systolic blood pressure, medication for hypertension, low serum HDL cholesterol, high or low serum creatinine, high AST or ALT, diabetes, low body mass index, current smoking, heavy drinking, and urinary protein among men. The predictive factors for cardiovascular disease were advanced age, high systolic blood pressure, medication for hypertension, low or high serum total cholesterol, low serum HDL cholesterol, high serum creatinine, diabetes, low body mass index, current smoker, and urinary protein, and those for cancer were advanced age, medication for hypertension, low serum HDL cholesterol, low serum creatinine, high AST or ALT, diabetes, low body mass index, current smoking, heavy drinking and urinary protein. Furthermore, those for stroke were advanced age, high systolic blood pressure, medication for hypertension, low serum HDL cholesterol, high serum creatinine, high AST or ALT, low body mass index, current smoking, while for coronary heart disease they were advanced age, high systolic blood pressure, high serum total cholesterol, low serum HDL cholesterol, diabetes, current smoking, and urinary protein among men. For women, similar predictive factors were obtained, although some of them did not reach statistical significance. CONCLUSION: We could construct predictive models for 5-year mortality rate from results of annual health checkups. These findings should prove useful for computerized health education on the prevention of stroke, coronary heart disease, and cancer.     

Coronary heart disease risk factors and attributable risks in African-American women and men: NHANES I epidemiologic follow-up study.

OBJECTIVES: This study assessed associations of risk factors with coronary heart disease incidence in African Americans. METHODS: The participants in the NHANES I Epidemiologic Follow-Up Study included in this analysis were 1641 Black and 9660 White persons who were aged 25 to 74 years when examined and who did not have a history of coronary heart disease. Average follow-up for survivors was 19 years. RESULTS: Significant, independent risk factors for coronary heart disease were age, systolic blood pressure, and smoking in Black women and age, systolic blood pressure, serum cholesterol, low education, and low family income in Black men. In this cohort, 19% of incident coronary heart disease in Black women and 34% in Black men might be prevented if systolic blood pressure were below 140 mm Hg. In Black men, attributable risk for low education (46%) was even higher than that for elevated blood pressure. CONCLUSIONS: Elevated systolic blood pressure and smoking were predictive of coronary heart disease incidence in African Americans. Estimates of population attributable risk were highest for elevated systolic blood pressure in women and education less than high school in men. Further studies of serum lipids, education, and coronary heart disease in Black women are needed.     

Sudden death in the Framingham Heart Study. Differences in incidence and risk factors by sex and coronary disease status

The frequency of and risk factors for sudden death in men and women with and without prior coronary heart disease were investigated in the population-based Framingham Heart Study. The cohort initially consisted of 2,336 men and 2,873 women. Over 26 years, 146 men died suddenly (46% of all male coronary heart disease deaths). A total of 69 men without and 77 men with prior evidence of coronary heart disease were victims of sudden death. Out of 50 sudden deaths in women (34% of female coronary heart disease deaths), 34 occurred in women without prior coronary disease and 16 in women with prior coronary disease. Incidence rates for sudden death were substantially greater in men than in women and in both men and women with, as opposed to without, prior coronary heart disease. The classic coronary heart disease risk factors, left ventricular hypertrophy, age, serum cholesterol, number of cigarettes smoked daily, relative weight, and systolic blood pressure, emerged from multiple logistic regression analysis of sudden death in men without prior coronary heart disease. However, in men with prior coronary disease, only left ventricular hypertrophy and intraventricular block, and no other classic risk factors, were positive predictors of sudden death. For women without prior coronary disease, significant factors were age, vital capacity, hematocrit, serum cholesterol (marginal), and serum glucose (marginal). In women with prior coronary disease, only hematocrit was a consistent predictor. Reasons for the substantial differences in sudden death risk profiles between men and women are not entirely clear, but limitations in data may partially account for these sex differences.     

Mortality from coronary heart disease in the Tecumseh study. Long-term effect of diabetes mellitus, glucose tolerance and other risk factors

The coronary heart disease mortality of participants in the Tecumseh study was examined with particular emphasis on the roles of diabetes and glucose tolerance as risk factors. The cohort consisted of 921 men and 937 women aged 40 years and older who did not have evident coronary heart disease at entry to the study during the period 1959-1965 and whose outcome was determined in the period 1977-1979. Previously diagnosed diabetes was a statistically significant risk factor for coronary heart disease mortality in both sexes even after controlling for systolic blood pressure, serum cholesterol, relative weight, and cigarette smoking. High blood glucose score in nondiabetics was associated with excess coronary heart disease mortality after controlling for other risk factors, but the magnitude of this effect was substantially below that of diabetes. The predictive power of most risk factors except age itself decreased among progressively older segments of the population.     

Risk factors for ischaemic heart disease: the prospective phase of the British Regional Heart Study.

Risk factors for major ischaemic heart disease (acute myocardial infarction or sudden death) have been investigated in a prospective study of 7735 men aged 40-59 years drawn from general practices in 24 British towns. After a mean follow-up of 4.2 years, there have been 202 cases of major ischaemic heart disease. Univariate estimates of the risk of ischaemic heart disease show that serum total cholesterol, HDL-cholesterol and triglyceride concentrations, systolic and diastolic blood pressures, cigarette smoking, and body mass index are all associated with increased risk of ischaemic heart disease. Evidence of ischaemic heart disease at initial examination is also strongly associated with increased risk of subsequent ischaemic heart disease. All these factors were then considered simultaneously using multiple logistic models. Definite myocardial infarction on electrocardiogram and recall of a doctor diagnosis of ischaemic heart disease remained predictive of subsequent major ischaemic heart disease, after allowance for all other risk factors. Serum total cholesterol, blood pressure, and cigarette smoking each remained as highly significant independent risk factors whereas overweight, above average levels of HDL-cholesterol and serum triglyceride were not predictive of risk after allowance for the above factors. Men with and without pre-existing ischaemic heart disease were examined separately in the same way (using multiple logistic models). The strength of association between the principal risk factors and subsequent major ischaemic heart disease was reduced in the men with pre-existing ischaemic heart disease, only age and serum total cholesterol remaining highly significant. Overall the levels of the major risk factors commonly encountered in British men have a marked effect on the risk of ischaemic heart disease. Modification of these risk factors in the general population constitutes an important national priority.     

Predictors of cardiovascular events and mortality in the Systolic Hypertension in the Elderly Program pilot project

Do the established cardiovascular risk factors for younger persons remain important predictors of cardiovascular disease events and mortality in those who are older? The authors examined this question in the Systolic Hypertension in the Elderly Program pilot project which prospectively followed 551 men and women 60 years of age and older with pretreatment systolic blood pressure greater than or equal to 160 mmHg and diastolic blood pressure less than 90 mmHg who were enrolled between May 1981 and July 1982. Mean age was 72 years, 37% were men, 82% were white, and 24% had attended college. The vital status of all 551 participants was known at the end of follow-up, an average of 34 months after entry; there were 39 deaths from all causes, 66 first cardiovascular events, 18 strokes, and 20 episodes of myocardial infarction/sudden death. Univariate Cox proportional hazard analysis revealed that age was a predictor (p less than 0.05) of all-cause mortality, first cardiovascular event, and stroke. Less than college education was a predictor of all-cause mortality and first cardiovascular event, smoking was a predictor of first cardiovascular event and myocardial infarction/sudden death, cholesterol was a predictor of first cardiovascular event, and lower body mass index was a predictor of increased all-cause mortality. After adjustment for covariables, age, lower education, lower body mass index, and baseline electrocardiographic abnormalities were significant predictors of all-cause mortality, and age, lower education, history of cardiovascular event, and smoking remained significant predictors of first cardiovascular event. Sex was not a risk factor, and the ability to examine hypertension as a risk factor was impaired by the fact that the entire cohort had systolic hypertension at baseline, and most were treated. These findings, combined with prior evidence, suggest that smoking, low education level, and perhaps serum cholesterol are risk factors for cardiovascular disease in the elderly. Although the excess risk conveyed by these factors is large, its reversibility needs to be demonstrated by intervention studies.     

Parental history of coronary heart disease, hypertension, diabetes, and stroke: Relationship to coronary heart disease risk factor variables in their adult children

Relationships of parental (familial) history of coronary heart disease, stroke, hypertension, and diabetes to major coronary heart disease (CHD) risk factors were examined in 738 adults (average age, 40 years) in the Cincinnati Lipid Research Clinics Princeton School study. Men reporting parental CHD had higher plasma triglyceride and higher systolic and diastolic blood pressure than comparison group men reporting no parental CHD, stroke, hypertension, or diabetes. Women reporting parental CHD had higher plasma triglycerides than comparison group women reporting no parental CHD, stroke, hypertension, or diabetes. Men reporting stroke in one parent had higher total plasma cholesterol and triglyceride levels than comparison men. Women reporting stroke in one parent had higher triglyceride levels than comparison group women. Women reporting hypertension in one parent had higher mean triglyceride and systolic blood pressure than comparison women. Men and women reporting diabetes in one parent had higher triglyceride than comparison adults. Matching men whose fathers had died of CHD with those whose fathers were free of CHD revealed significant increments in triglyceride levels, systolic, and diastolic blood pressure in the men with positive family history of CHD. Matching women whose fathers had died of CHD with those whose fathers were free of CHD revealed higher total plasma cholesterol, low-density lipoprotein cholesterol, and Quetelet index. In men, categorical assessment by CHD risk factor levels (low, intermediate, high), revealed that plasma triglycerides and systolic blood pressure were positively associated with a parental history of CHD, while high-density lipoprotein cholesterol was inversely related. In women, similar observations were made for triglycerides. Family history is a practical tool for identification of risk to CHD, hypertension, stroke, and diabetes. Serial risk factor measurements in offspring from CHD-, hypertension-, stroke-, and diabetes-positive families should have considerable utility in early recognition and documentation of CHD risk factor levels which, in turn, should facilitate primary intervention designed to ameliorate or prevent the development of CHD.     

Coffee drinking is dose-dependently related to the risk of acute coronary events in middle-aged men

Heavy coffee consumption has been associated with increased coronary heart disease (CHD) risk although many studies have not observed any relation. We studied the effect of coffee consumption, assessed with a 4-d food record, on the incidence of nonfatal acute myocardial infarction or coronary death in a cohort of 1971 men who were 42 to 60 y old and free of symptomatic CHD at baseline in 1984-1989. During a mean follow-up of 14 y, 269 participants experienced an acute coronary event. After adjustment for age, smoking, exercise ischemia, diabetes, income, and serum insulin concentration, the rate ratios (95% CIs) in daily nondrinkers and light (375 mL or less), moderate (reference level), and heavy (814 mL or more) drinkers were 0.84 (0.41-1.72), 1.22 (0.90-1.64), 1.00, and 1.43 (1.06-1.94). To address time dependence of the effect, the analysis was repeated for 75 CHD events that occurred during the first 5 y; the respective rate ratios were 0.42 (0.06-3.10), 2.00 (1.16-3.44), 1.00, and 2.07 (1.17-3.65). Further adjustment for serum HDL and LDL cholesterol concentration, diastolic blood pressure, maximal oxygen uptake, and waist-hip ratio slightly increased the rate ratio for heavy coffee intake. Neither the brewing method (boiling vs. filtering) nor the serum LDL cholesterol concentration had any impact on the risk estimates for coffee intake. In conclusion, heavy coffee consumption increases the short-term risk of acute myocardial infarction or coronary death, independent of the brewing method or currently recognized risk factors for CHD.     

Serum C-reactive protein and fibrinogen concentrations and self-reported angina pectoris and myocardial infarction: findings from National Health and Nutrition Examination Survey III

C-reactive protein may predict the risk of cardiovascular disease, but its association with angina pectoris in the general population has not been clearly established, however. We used data from National Health and Nutrition Examination Survey III conducted from 1988-1994 to examine the associations between serum C-reactive protein and plasma fibrinogen concentrations and self-reported angina pectoris and myocardial infarction among 7,948 U.S. men and women aged 40 years and older. C-reactive protein and fibrinogen concentrations were moderately correlated (r = 0.43). After adjustment for age, sex, race or ethnicity, education, smoking status, systolic blood pressure, serum cholesterol, high-density lipoprotein cholesterol, history of diabetes mellitus, body mass index, and physical activity, fibrinogen (but not C-reactive protein) concentration was significantly associated with self-reported angina pectoris. Neither fibrinogen or C-reactive protein concentrations were significantly associated with angina pectoris when entered in the model simultaneously. C-reactive protein and fibrinogen concentrations were positively associated with myocardial infarction when entered separately into models, but only C-reactive protein concentration was significantly associated with myocardial infarction when both variables were entered simultaneously. These cross-sectional data showed a significant positive association between C-reactive protein concentration and myocardial infarction but not self-reported angina pectoris in the U.S. population.     

The inverse relation of average population blood pressure and stroke mortality rates in the seven countries study: A paradox

This study attempts to explain the unexpected finding of an inverse population (ecological) relationship between mean systolic blood pressure levels and stroke death rates in 25 years follow-up of the Seven Countries Study, a cross-cultural study of cardiovascolar disease. Sixteen cohorts of all men aged 40–59 in seven countries (one cohort in the USA, two in Finland, one in the Netherlands, three in Italy, two in Croatia (former Yugoslavia), three in Serbia (former Yugoslavia), two in Greece, two in Japan) were surveyed from 1958 to 1964. Risk factors and personal characteristics were measured and follow-up for vital status and cause of death was then carried out over 25 years. Analyses were based on comparisons of mean levels of risk factors and death rates within and among the 16 cohorts. Mean entry population levels of systolic blood pressure among the cohorts were strongly and inversely related with their 25-year stroke death rates (R –0.55; CI –0.81 and –0.06; p = 0.0276). Within cohorts in contrast, the individual relation of blood pressure and stroke was strongly positive and significant in 14 of the 16 cohorts. Mean population levels of serum cholesterol were inversely and strongly related to stroke death rates (R –0.79; CI –0.92 and –0.46; p = 0.0003), while the partial correlation coefficient of systolic blood pressure, computed in models including serum cholesterol, became small and not significant (– 0.05; CI –0.55 and +0.48; p = 0.8537). Age at death for stroke (average 68.9 ± 7.1 years) was significantly higher than age at death from myocardial infarction and sudden death (average 65.8 ± 7.8 years) suggesting a competition effect between the conditions. Multivariate models including population average systolic blood pressure and serum cholesterol provided no added explanation for the lack of direct and significant relationship of population blood pressure with stroke death rates. They were base on these variables: age at stroke death, age at myocardial infarction death or and sudden death, death rates from myocardial infarction and sudden death, the interaction term of systolic blood pressure with serum cholesterol and the multivariate coefficients for systolic blood pressure from Cox models run in individuals. Similar findings were obtained using diastolic instead of systolic blood pressure and excluding the Japanese cohorts. The paradox of the inverse ecologic relation of population blood pressure and stroke mortality and a direct relation for individual is only partly explained by the cofounding effect of population mean serum cholesterol levels. An effect of low cholesterol levels on excess stroke mortality cannot be excluded. A major limitation of the study was our inability to segregate thrombotic from heamorrhagic strokes.     

Sex differences in the coronary heart disease risk profile: a possible role for insulin. The Beaver County Study

The mortality rate from coronary heart disease is much higher among men than women except in diabetes mellitus, which appears to reduce this sex difference. It is hypothesized that the female advantage is due, at least partly, to the more efficient insulin mediated glucose homeostasis in females, an advantage lost in the diabetic state. The authors studied 170 young adult men and women aged 20-24 years from a population-based survey in Beaver County, Pennsylvania, in 1981-1982, in an attempt to further elucidate the sex-specific relationships between fasting serum insulin concentrations and several risk factors. Women who used oral contraceptives and subjects whose fasting serum glucose exceeded 110 mg/dl were excluded. Insulin was related to body mass index in both sexes (r = 0.31; p less than 0.01 for men; r = 0.26, p less than 0.01 for women) and to systolic blood pressure (r = 0.27, p less than 0.01 for men; r = 0.36, p less than 0.001 for women). Insulin was related to diastolic blood pressure in men only (r = 0.31, p less than 0.05). Multivariate analysis revealed fasting serum insulin to be an independent predictor of systolic blood pressure in both sexes and of diastolic blood pressure in men only. Insulin was inversely related to high density lipoprotein cholesterol only among men and this relationship appeared to be largely independent of body mass index and triglycerides. Results indicate that insulin concentration is associated with an adverse coronary heart disease risk factor profile especially among men, consistent with their excess risk of cardiovascular disease.     

A randomized primary preventive trial in coronary heart disease: The oslo study

One thousand, two hundred thirty-two healthy, normotensive, but coronary high-risk men were selected for a 5-year randomized trial to assess if dietary control of hypercholesterolemia and cessation of cigarette smoking are effective in the primary prevention of coronary heart disease. The men included in the trial had serum cholesterol levels between 7.5 mmol/l (290 mg/dl) and 9.8 mmol/l (380 mg/dl), coronary risk score (based on cholesterol, smoking, and blood pressure) in the upper quartile of the distribution, and systolic blood pressure <150 mm Hg. The men in the intervention group were advised to stop smoking and to lower their blood lipids by dietary changes. On average, mean serum cholesterol concentration was 13% lower in the intervention group compared with the controls during the 5 years of the trial. Mean fasting serum triglycerides decreased by 20% in the intervention group compared with the control group. On the average, tobacco consumption was reduced about 45% in the intervention group compared to controls during the study. (Eighty percent of the men in both groups were daily cigarette smokers at the start of the study.) Diagnoses of events of cardiovascular disease during the 5 years were made blindly according to predefined criteria, by a diagnostic board not involved in the study. At the end of the observation time the incidence of myocardial infarction (fatal and nonfatal) and sudden death was 47% lower in the intervention group than in the controls (P = 0.028, 2-sided test). It is concluded that in healthy, coronary high-risk, middle-aged men, advice to change eating habits and to stop smoking significantly reduces the incidence of first events of myocardial infarction and sudden death.     

The relation between serum albumin levels and risk of coronary heart disease in the Multiple Risk Factor Intervention Trial.

The relation between serum albumin levels and subsequent incidence of myocardial infarction and coronary heart disease deaths was evaluated using stored serum from the Multiple Risk Factor Intervention Trial (MRFIT). There were 91 coronary heart disease deaths, 113 myocardial infarction patients, and 405 controls matched to cases within 5 years of age, treatment group, and clinic site. There was a highly significant inverse relation between serum albumin level and risk of coronary heart disease. Individuals with a baseline level of serum albumin greater than or equal to 4.7 g/dl had an odds ratio of 0.45 as compared with individuals with a baseline level of serum albumin less than 4.4 g/dl. The relation persisted after adjusting for other cardiovascular risk factors (blood pressure, smoking, and serum cholesterol). The association was stronger for coronary heart disease deaths than for surviving myocardial infarction patients, and for cigarette smokers as compared with cigarette nonsmokers. The deaths studied occurred in the time period at least 6 years after the sera had been obtained and up to 10.5 years of follow-up, and the myocardial infarctions studied occurred within the first 6.5 years of follow-up. There was no consistent relation between time and death due to coronary heart disease or myocardial infarction and albumin levels. Albumin levels are related to the acute phase reaction. Lower albumin levels may be a marker of persistent injury to arteries and progression of atherosclerosis and thrombosis. The consistent relation between albumin and coronary heart disease risk requires further evaluation.     

Peak expiratory flow and risk of cardiovascular disease and death. A 12-year follow-up of participants in the population study of women in Gothenburg, Sweden

A longitudinal population study of 1,462 women, aged 38-60 years at entry, was begun in Gothenburg, Sweden, in 1968-1969. This paper deals with the first 12-year follow-up period. In univariate analysis, peak expiratory flow showed a significant negative correlation with the 12-year incidences of myocardial infarction, electrocardiographic changes suggesting ischemic heart disease, stroke, and death. The association with incidence of myocardial infarction, stroke, and death remained in multivariate analysis, and was independent of age, body height, body mass index, adipose tissue distribution, chest deformity, history of pulmonary disease, smoking habit, serum cholesterol concentration, serum triglyceride concentration, systolic blood pressure, diabetes, and physical activity. The findings indicate that measuring peak expiratory flow is a simple procedure to identify women with an increased risk of cardiovascular disease or death. It seems urgent to find out what preventive measures might be taken as a consequence of these observations.     

Trends in selected biological risk factors for cardiovascular diseases in the Danish MONICA population, 1982-1992

Data from 6695 men and women of ages 30, 40, 50, and 60 years, examined in the Danish WHO MONICA surveys in 1982-84, in 1986-87, and in 1991-92, were analyzed to estimate secular trends in body height and weight, blood pressure, and serum total, HDL-, and LDL-cholesterol, and triglyceride. Body height increased 0.1% per year, and body mass index increased 0.4% per year in women. Diastolic blood pressure increased 0.4% per year in women and 0.6% per year in 60-year-old men. HDL cholesterol declined 0.4% per year. Body mass indices in men, diastolic blood pressures in men <60 years of age, systolic blood pressures, total- and LDL cholesterol and triglyceride did not change. The levels of biological risk factors in the Danish WHO MONICA study population did not show trends during the 1980s that help explain the declining incidence of myocardial infarction in the population.