Elevated serum bilirubin may significantly reduce coronary heart disease risk in females: A prospective cohort study

Background and aimsThere is still inconsistent evidence over the protective effect of total bilirubin on the development of coronary heart disease (CHD). Therefore, we aimed to investigate the association between bilirubin in population subtypes and the risks of CHD between different gender and menstruation subgroups.Methods and resultsIn this prospective cohort study, 29,750 participants free of CHD with an average age of 47 ± 14 years were recruited at baseline; of these, 720 CHD first-attack cases were collected after 7-years of follow up. The covariate-adjusted Cox proportional hazards models were used to estimate hazard ratios (HRs) of CHD with 95% confidence intervals (CIs). The serum bilirubin concentration was quarterly stratified based on the distribution of healthy population without CHD onset. The HRs of incident CHD decreased with elevated bilirubin in females (ρ trend<0.05), but not males. In postmenopausal females, compared with the lowest quartile of total bilirubin, the adjusted HRs for the third and fourth quartiles were 0.64 (95% CI: 0.45, 0.93) and 0.59 (95% CI: 0.42, 0.86), the adjusted HRs in the third and fourth quartiles of direct bilirubin were 0.56 (0.39, 0.82) and 0.56 (0.38, 0.81), and for indirect bilirubin, corresponding HR in the highest quartile was 0.56 (0.38, 0.83).ConclusionElevated serum bilirubin was inversely associated with adjusted HRs of CHD in females, especially postmenopausal females. The relationship between elevated direct bilirubin and reduced HRs of CHD may be closer than indirect bilirubin in postmenopausal females.     

Microalbuminuria and mortality in individuals with coronary heart disease: A meta-analysis of a prospective study

AimMicroalbuminuria has been elevated as an outcome predictor in cardiovascular medicine. However, due to the small number of studies investigating the association of microalbuminuria and mortality in the coronary heart disease (CHD) population, the prognosis value of microalbuminuria in CHD remains under debate. The objective of this meta-analysis was to investigate the relationship between microalbuminuria and mortality in individuals with CHD.MethodA comprehensive literature search was performed using Pubmed, EuroPMC, Science Direct, and Google Scholar from 2000 to September 2022. Only prospective studies investigating microalbuminuria and mortality in CHD patients were selected. The pooled effect estimate was reported as risk ratio (RR).Results5176 patients from eight prospective observational studies were included in this meta-analysis. Individuals with CHD have a greater overall risk of all-cause mortality (ACM) [rR = 2.07 (95% CI = 1.70–2.44); p = 0.0003; I² = 0.0%] as well as cardiovascular mortality (CVM) [rR = 3.23 (95% CI = 2.06–4.39), p < 0.0001; I² = 0.0%]. Subgroup analysis based on follow-up duration and a subset of CHD patients were similarly associated with an increased risk of ACM.ConclusionThis meta-analysis indicates that microalbuminuria is associated with a higher risk of mortality in individuals with CHD. Microalbuminuria can serve as a predictor of poor outcomes in CHD patients.     

Stroke and coronary heart disease in treated hypertension -- a prospective cohort study over three decades

OBJECTIVE: To compare cardiovascular mortality and morbidity in middle-aged hypertensive men with initially nonhypertensive men derived from the same random population sample, and to study stroke morbidity in these men in relation to cardiovascular risk factors during 25-28 years of follow-up. DESIGN: Prospective, population-based observational study in men where the main intervention effort was directed towards treatment of hypertension in a special outpatient clinic. SUBJECTS AND METHODS: A total of 754 hypertensive men aged 47-55 years at screening were compared with 6740 men with normal blood pressure. The hypertensive men got stepped care treatment with either beta-blockers, thiazide diuretics, or combination treatment including vasodilating agents during the whole observational period. Data on cause-specific mortality and morbidity, and all cause mortality were obtained from patient files and the national registers on mortality and hospital admissions respectively. MAIN OUTCOME MEASURES: Baseline and change of cardiovascular risk factors during the first 15 years of follow-up and all cause mortality, and mortality and morbidity from stroke and coronary heart disease during 25-28 years. RESULTS: Treated hypertensive men had their blood pressure reduced with 21/15 mmHg during the first 5 years of the study and mean blood pressure levels were then rather constant. A minor reduction of serum cholesterol was also observed and a significant reduction in the prevalence of smoking. Treated hypertensive men suffered a substantial increased incidence of cardiovascular complications that escalated during the latter course of the study. Their total incidence of stroke was doubled; they had 50% more myocardial infarctions (MIs); mortality from coronary heart disease was doubled and all cause mortality was increased by a third, compared with nonhypertensive. In multiple regression analysis the incidence of stroke was significantly related to smoking and diabetes at entry and in time-dependent Cox's regression analysis it was significantly related only to smoking. There was no relationship observed between achieved systolic or diastolic blood pressure and the risk of stroke or MI nor was there any relationship between the change in blood pressure and such cardiovascular complications. CONCLUSION: In spite of a substantial reduction of their blood pressure, treated hypertensive middle-aged men had a highly increased risk of stroke, MI and mortality from coronary heart disease compared with nonhypertensive men of similar age. The increased risk of cardiovascular complications escalated during the latter course of the study.     

Representativeness of the Framingham risk model for coronary heart disease mortality: a comparison with a national cohort study

The Framingham Heart Study has been the foundation upon which several national policies regarding risk factors for coronary heart disease mortality are based. The NHANES I Epidemiologic Followup Study is the first national cohort study based upon a comprehensive medical examination of a probability sample of United States adults. The average follow-up time was 10 years. This study afforded an opportunity to evaluate the generalizability of the Framingham risk model, using systolic blood pressure, total cholesterol, and cigarette smoking, to the U.S. population with respect to predicting death from coronary heart disease. The Framingham model predicts remarkably well for this national sample. The major risk factors for coronary heart disease mortality described in previous Framingham analyses are applicable to the United States white adult population.     

Increasing evidence-based treatments to reduce coronary heart disease mortality in Sweden: quantifying the potential gains

Abstract. Björck L, Capewell S, Bennett K, Lappas G, Rosengren A (Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden; University of Liverpool, Liverpool, United Kingdom; Trinity College and St. James’s Hospital, Dublin, Ireland). Increasing evidence‐based treatments to reduce coronary heart disease mortality in Sweden: quantifying the potential gains. J Intern Med 2011; 269 : 452–467. Objectives. Between 1986 and 2002, coronary heart disease (CHD) mortality in Sweden fell by more than 50%. Approximately one‐third (4800 fewer deaths) of this decline in age‐adjusted CHD mortality could be attributed to treatments in patients with CHD and primary prevention medications. High treatment levels were achieved in some cases, but in others, only 50–80% of eligible patients received appropriate therapy. We therefore examined to what extent increasing the use of specific treatments in eligible patients might have reduced CHD mortality rates in Sweden. Design and methods. We used the previously validated IMPACT CHD model to combine data on CHD patient numbers, medical and surgical uptake levels and treatment effectiveness. We estimated the number of deaths prevented or postponed for 2002 (baseline scenario) and for an alternative scenario (if at least 60% of eligible patients were treated). Results. If treatments were increased to consistently cover at least 60% of eligible patients, approximately 8900 deaths could have been postponed or prevented, representing a potential gain of approximately 4100 fewer deaths than actually occurred in 2002. Approximately 45% of the 4100 gain would have come from primary prevention with statins, 23% from acute coronary syndrome treatments, 15% from secondary prevention therapies and 15% from treatments for heart failure. Conclusion. Increasing the proportion of eligible patients with CHD who receive evidence‐based treatment could have resulted in approximately 4100 fewer deaths in 2002, almost doubling the actual mortality reduction. These findings further emphasize the importance of aggressively identifying and treating patients with CHD and high‐risk individuals.     

Diabetes, mortality and coronary heart disease in the prospective Dubbo study of Australian elderly

Background: A prospective study of Australian elderly living in Dubbo has shown that diabetes is a significant predictor of all-causes mortality and coronary heart disease (CHD). Aim: To examine and contrast clinical and socio-demographic predictors of these outcomes in those with and without diabetes. Methods: The data are derived from a community-based sample of subjects 60 years and older followed over 62 months since 1988. Of 1155 men and 1472 women, 9.2% and 6.9% respectively manifested diabetes at baseline, based on history or fasting hyper-glycaemia. Results: In the presence of diabetes, all-causes mortality was increased twofold in both sexes, CHD incidence was increased twofold in men and threefold in women, stroke incidence was increased twofold in women but little changed in men. Proportional hazards models were derived separately for persons with and without diabetes and risk factors differentially predictive in diabetes were sought. Significant predictors of death in diabetes were old age and current smoking. Those factors differentially predictive were ‘being married’ (Relative Risk [RR] 1.60 with diabetes and 0.69 without diabetes) and higher body mass index (BMI) (RR 1.03 with diabetes and 0.79 without diabetes). Significant predictors of CHD in diabetes were old age, prior CHD, severe hypertension, low HDL cholesterol and self-rated health. Those factors differentially predictive were higher body mass index (RR 1.14 vs 0.83) and physical disability (RR 0.69 vs 1.55). Differential predictions with regard to BMI may relate in part to excess CHD and mortality at low BMI in non-diabetic subjects. Conclusion: The vascular disease burden of diabetes in the elderly has been confirmed, especially in women. A number of conventional risk factors are contributing to this burden and may be amenable to treatment.     

Therapy to reduce risk of coronary heart disease

Recent primary and secondary intervention studies have shown that reduction of low-density lipoprotein cholesterol (LDL-C) with statins significantly reduced coronary heart disease (CHD) morbidity and mortality. However, many patients with dyslipidemia who have or are at risk for CHD do not reach target LDL-C goals. The recently updated National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III guidelines identify a group of patients at very high risk for CHD for more aggressive LDL-C reduction and reaffirm the importance of high-density lipoprotein cholesterol (HDL-C) by raising the categorical threshold to 40 mg/dl. Lipid-lowering therapy needs to be more aggressive in both primary and secondary prevention settings, and therapy should be considered to increase HDL-C as well as lower LDL-C in order to improve patient outcomes. Both combination therapy and the next generation of statins may provide improved efficacy across the dyslipidemia spectrum.     

东亚男性饮酒与冠心病的关系

目的 探讨东亚男性饮酒对冠心病发病率、病死率和全因死亡率的影响.方法 检索Pubmed等数据库,纳入中国、日本、韩国符合入选条件的前瞻性队列研究.记录研究来源国家,例数,性别,年龄,随访期限,饮酒量,与饮酒相关的冠心病发病率、病死率及全因死亡率的相对风险等资料.应用荟萃分析,系统评价饮酒量与冠心病发病率、病死率及全国死亡率的风险效应.结果 纳入前瞻性队列研究15项;共计汇总冠心病研究对象177 723例,含冠心病患者2406例;全因死亡研究对象216 233例,含各种原因死亡15 462例.与不饮酒者比较,每日饮酒量≤20、21～40、41～60、＞60g/d者冠心病发病风险分别为0.65(95%CI:0.34～1.23,P=0.18)、0.48(95%CI:0.26～0.87,P=0.02)、0.46(95%CI:0.32～0.67,P＜0.01)和0.48(95%CI:0.29～0.78,P＜0.01),冠心病死亡风险分别为0.98(95%CI:0.73～1.31,P=0.87)、0.68(95%CI:0.58～0.79,P＜0.01)、0.64(95%CI:0.43～0.96,P=0.03)和0.75(95%CI:0.54～1.03,P=0.08),全因死亡风险分别为0.83(95%CI:0.79～0.91,P＜0.01)、0.93(95%CI:0.87～0.99,P=0.03)、1.01(95%CI:0.95～1.07,P=0.86)和1.32(95%CI:1.29～1.36,P＜0.01).结论 东亚男性适量饮酒可降低冠心病发病率及病死率.随着饮酒量增加,全因死亡的风险明显增加.每日饮用酒精量不应超过40g.     

Barriers to preventive interventions for coronary heart disease

Many barriers exist to the delivery of preventive services by cardiologists and other physicians. Appropriate training and the development of supportive infrastructures can effectively overcome these barriers. In addition, institutional priorities must change to encourage such efforts. Cardiologists must continue to recognize the importance of risk-factor modification, and training programs in cardiology should teach appropriate counseling techniques, the use of risk-factor-lowering pharmacologic agents, and the manner in which cardiologists should interface with dietitians and other ancillary personnel [77]. In addition, it is important to recognize and teach, both didactically and by example, that counseling patients and carrying out long-term preventive interventions can be as gratifying and interesting as performing dramatic procedures that, although valuable and rewarding, take place at a very late point in the patient's clinical course, a point that might have been averted by greater attention to risk-factor modification. Increasingly, the public and governmental agencies are becoming involved in encouraging such an approach [66], and health care provider groups [78] and organizations [67] are also facilitating the development of a more comprehensive approach to the delivery of preventive intervention [79].     

Pregnancy outcomes in myeloproliferative neoplasms: UK prospective cohort study

The reported higher risk of maternal and fetal complications in women with myeloproliferative neoplasms (MPN) poses challenge during pregnancy. A national prospective study of maternal and fetal outcomes of pregnant women with a diagnosis of MPN was undertaken via the United Kingdom Obstetric Surveillance System between January 2010 and December 2012. Fifty‐eight women with a diagnosis of MPN were identified; 47 (81%) essential thrombocythaemia, five (9%) polycythaemia vera, five (9%) myelofibrosis and one (2%) MPN‐unclassified. There were 58 live births. The incidence of miscarriage was 1·7/100 (95% confidence interval [CI]: 0·04–9·24) and the perinatal mortality rate was 17/1000 (95% CI: 0·44–92·36) live and stillbirths. Incidence of maternal complications was 9% (5/57) pre‐eclampsia, 9% (5/57) post‐partum haemorrhage and 3·5% (2/57) post‐partum haematoma. There were no maternal deaths or thrombotic events. Delivery was induced in 45% (24/53) of women and the Caesarean section rate was 45% (24/53). The majority (85%, 45/53) delivered at term (>37 weeks gestation). Twenty‐two percent (12/54) of neonates were below the 10% centile for growth and 13% (7/54) required admission to a neonatal care‐unit; there were no neonatal deaths. The findings of this large, UK prospective study suggests women with MPN appear to have successful pregnancies with better outcomes than would be anticipated from the literature.