Validation of reported myocardial infarction mortality in blacks and whites. A report from the Community Cardiovascular Surveillance Program.

It is widely believed that blacks experience a higher mortality due to coronary heart disease (CHD) than do whites. To determine whether this reported difference in mortality between blacks and whites is real, we studied the question in the context of the Community Cardiovascular Surveillance Program (CCSP). Fatal and nonfatal cases of CHD were reviewed in 12 US communities. Standardized criteria were applied to classify these cases as possible CHD, definite CHD, possible myocardial infarction (MI), or definite MI. The annual age-adjusted mortality rate per 100,000 ascribed to definite MI by the CCSP criteria was higher in blacks than in whites: 47 in white men (95% confidence interval, 36 to 58), 18 in white women (95% confidence interval, 8 to 28), 95 in black men (95% confidence interval, 10 to 180), and 41 for black women (95% confidence interval, 0 to 99). The proportion of definite MI to all fatal CHD events was higher in blacks (16%) than in whites (12%). For nonfatal events, however, the rate of definite MI was higher in whites than in blacks: 322 in white men (95% confidence interval, 293 to 351), 225 in black men (95% confidence interval, 160 to 290), 82 in black women (95% confidence interval, 43 to 121), and 103 in white women (95% confidence interval, 88 to 118). The proportion of definite MI to all nonfatal CHD events was lower in blacks (16%) than in whites (30%). Thus, the overall rate for fatal and nonfatal definite MI was lower in blacks (215/100,000) than in whites (244/100,000). These observations suggest that a combination of high case-fatality ratio and misclassification of cause and death may contribute to the reported higher rate of CHD mortality among blacks.     

Erythrocyte sedimentation rate, an independent predictor of coronary heart disease in men and women: The Reykjavik Study

The relation between erythrocyte sedimentation rate (ESR) and risk of developing coronary heart disease (CHD) or fatal cerebrovascular accident was assessed in a cohort of 7,988 men and 8,685 women who participated in The Reykjavik Study (Iceland). Cardiovascular risk assessment was based on characteristics at baseline, from 1967 to 1996. During an average follow-up of 19 and 20 years, 2,092 men and 801 women, respectively, developed CHD, and 251 men and 178 women died from cerebrovascular accident. For men, the fully adjusted increase in risk of developing CHD predicted by the top compared with the bottom quintile of ESR was 57% (hazard ratio = 1.57, 95% confidence interval: 1.38, 1.78; p < 0.001); for women, risk was increased by 49% (hazard ratio = 1.49, 95% confidence interval: 1.16, 1.90; p < 0.001). The increased risk after baseline ESR measurement was stable for up to 25 years for men and 20 years for women. The fully adjusted risk of death due to stroke predicted by increasing the ln(ESR + 1) by one standard deviation was increased by 15% for men (p = 0.06) and 16% for women (p = 0.08). In conclusion, ESR is a long-term independent predictor of CHD in both men and women. These findings support the evidence of an inflammatory process in atherosclerosis.     

Psychosocial determinants of coronary heart disease in middle-aged women: a prospective study in Sweden

A social gradient in coronary heart disease (CHD) has been documented in a variety of settings, predominantly among men. This study aimed to establish whether a social gradient in CHD existed in a group of Swedish women and whether it could be explained by established coronary risk factors or psychosocial factors. The Women's Lifestyle and Health Cohort Study includes 49,259 women from Sweden aged 30-50 years at baseline (1991-1992), when an extensive questionnaire was completed. There was complete follow-up through linkages to national registries until the end of 2002, during which time 210 cases of incident fatal CHD or nonfatal myocardial infarction occurred. Risk of CHD was significantly inversely related to years of education, the socioeconomic status proxy (hazard ratio comparing the lowest with the highest education group = 3.3, 95% confidence interval: 2.2, 4.7). This association was reduced after adjustment for established coronary risk factors (smoking, body mass index, alcohol consumption, diabetes, hypertension, exercise; hazard ratio = 1.9, 95% confidence interval: 1.3, 2.8). Job strain and social support were weakly related to CHD and did not explain the gradient by years of education. Self-rated health was strongly related to CHD, mediated by established coronary risk factors. Results show a strong gradient in CHD by years of education explained by established coronary risk factors but not by job strain or social support.     

Ten-year incidence of coronary heart disease in the Honolulu Heart Program. Relationship to biologic and lifestyle characteristics

In 10 years of follow-up of 7705 Japanese men living in Hawaii, aged 45-68 years and judged free of coronary heart disease (CHD) at the initial examination during 1965-1968, a total of 511 new CHD cases were identified: fatal CHD, 139; nonfatal myocardial infarction (MI), 216; acute coronary insufficiency, 55; and uncomplicated angina pectoris (AP), 101. The incidence rate of fatal CHD and nonfatal MI for this cohort is less than half the rate for US whites and approximately twice the rate for Japanese men in Japan. The relationships of 14 biologic and lifestyle characteristics measured at baseline examination to the incidence of total CHD and specific manifestations of CHD were examined in bivariate and multivariate analyses. In bivariate analyses, all variables except heart rate were significantly related to the risk of total CHD after adjustment for age. However, when an independent contribution of each variable to CHD risk was evaluated in multiple logistic analyses in which all other variables were taken into account, the numbers of risk factors retaining significant associations varied by clinical subgroup of CHD. Among the characteristics studied, systolic blood pressure was the most powerful and consistent risk factor for all manifestations except AP. Cigarette smoking showed a similar pattern. Serum cholesterol was significantly associated with fatal CHD and nonfatal MI, but its contribution to CHD risk was less potent than systolic blood pressure or cigarette smoking. Glucose intolerance was strongly associated with fatal CHD, but with no other manifestations of CHD. Alcohol consumption demonstrated a strong protective effect upon fatal CHD and nonfatal MI. Uncomplicated AP was distinguished from other CHD manifestations by the lack of association with most of the known major risk factors for CHD, including blood pressure, serum cholesterol, and cigarette smoking.     

Vasectomy and subsequent cardiovascular disease in US physicians.

Due to previous animal research suggesting accelerated atherosclerosis following vasectomy, we examined whether vasectomy increases the risk of subsequent cardiovascular disease (CVD), including myocardial infarction (MI), angina pectoris, coronary revascularization, and stroke, in the US Physicians' Health Study. Of 22,071 US male physicians participating in the study, aged 40 to 84 years at entry and free from cardiovascular disease and cancer, 21,028 reported on the 60-month questionnaire whether they had undergone vasectomy prior to randomization. Of the 4546 physicians with vasectomy, 1159 had undergone the procedure at least 15 years before entry. During 258,892 person-years of follow-up, we documented 773 cases of MI (719 nonfatal and 54 fatal), 1907 cases of angina pectoris or coronary revascularization, and 604 confirmed cases of ischemic or hemorrhagic stroke (566 nonfatal and 38 fatal). When compared to men without prior vasectomy, the multivariate relative risk (RR) of total MI adjusted for age and other coronary risk factors was 0.94 (95% confidence interval [CI], 0.77-1.14) among men with vasectomy. Risk estimates for fatal and nonfatal events did not appreciably differ from each other. For angina or coronary revascularization or both, the multivariate relative risk was 0.99 (0.88-1.12) and for total stroke the RR was 0.95 (0.75-1.21). For men who had undergone vasectomy 15 or more years previously, the multivariate relative risks were 0.98 (0.73-1.32) for total MI, 1.17 (0.87-1.57) for total stroke, and 1.12 (0.94-1.35) for angina/revascularization. These results provide reassuring evidence that vasectomy does not materially increase the risk of subsequent cardiovascular disease, even 15 or more years following the procedure.     

Free protein S level as a risk factor for coronary heart disease and stroke in a prospective cohort study of healthy United Kingdom men

Plasma protein S (PS) levels are reportedly low in patients with venous thrombosis but high in coronary heart disease (CHD) patients. The authors examined the association between free PS concentration and CHD or stroke risk and assessed risk in combination with C-reactive protein (CRP) levels. Free PS concentration was determined in 6 annual visits among 3,052 middle-aged (49-64 years) United Kingdom men from the Second Northwick Park Heart Study, with 297 CHD events from 1989 to 2005. The highest (vs. first) quintile was associated with a significantly increased CHD risk after adjustment for all other risk factors and correction for regression dilution bias (hazard ratio = 1.85, 95% confidence interval: 1.08, 3.16; P = 0.024). Models that included all well-known risk factors plus PS quintiles improved prediction of CHD (net reclassification improvement (NRI) = 7.0% (P = 0.007), category-less NRI (>0) = 22.1% (P < 0.001)), and the likelihood ratio statistic increased significantly (P = 0.018). The increase in CHD risk was particularly strong when subjects also had high CRP levels. There was no association between free PS level and stroke risk. This study confirms the independent association of elevated free PS levels with future risk of CHD, although elevated PS levels added only modestly to prediction metrics. The novel finding of increased CHD risk, particularly when CRP and PS levels are high, requires further study.     

Long-term outcome of myocardial infarction in women and men: a population perspective

Because of women's survival advantage, the impact of myocardial infarction (MI) on long-term mortality in women compared with men may be underestimated. The authors examined this issue in a community sample of 2,462 persons aged > or = 65 years living in New Haven, Connecticut, who were free of MI at baseline and were followed for 10 years (1982-1992). By using proportional hazards models with MI hospitalizations and the sex-MI interaction as time-dependent covariables, survival for the MI cases from the date of MI was compared with survival of persons who, at the same follow-up time, were still alive and free of MI. Women survived longer than men mainly in the absence of MI. The multivariable-adjusted hazard ratios of death were 0.53 in the absence and 0.87 in the presence of MI, and MI was associated with a greater risk of death in women (adjusted hazard ratio = 5.9) than in men (adjusted hazard ratio = 3.6) (p = 0.01 for the sex-MI interaction). When out-of-hospital fatal infarctions were considered, the impact of MI on survival in women compared with men increased. In conclusion, in this elderly cohort, when viewed from a population perspective, MI had a greater impact on mortality in women and significantly narrowed women's typical survival advantage over men.     

Prevention of coronary heart disease: some results from the Oslo secondary and primary intervention studies

The increase in cardiac disease [fatal and nonfatal myocardial infarction (MI), and sudden death] in the post-war years in Norway, after the much lower incidence during the war, that coincided with high and low fat intakes, respectively, led to a trial in Oslo to determine whether lowering dietary fat intake would favorably influence occurrence of coronary heart disease (CHD). Dietary modification, which lowered serum cholesterol of men who had suffered a first-time MI, showed decreased reinfarction incidence and cardiac deaths as compared with a comparable group of controls. Another study of normotensive high-risk men (on the basis of serum cholesterol and smoking habits) showed that dietetic measures can be useful in preventing CHD.     

Symposium on Advances in Clinical Nutrition

The increase in cardiac disease [fatal and nonfatal myocardial infarction (MI), and sudden death] in the post-war years in Norway, after the much lower incidence during the war, that coincided with high and low fat intakes, respectively, led to a trial in Oslo to determine whether lowering dietary fat intake would favorably influence occurrence of coronary heart disease (CHD). Dietary modification, which lowered serum cholesterol of men who had suffered a first-time MI, showed decreased reinfarction incidence and cardiac deaths as compared with a comparable group of controls. Another study of normotensive high-risk men (on the basis of serum cholesterol and smoking habits) showed that dietetic measures can be useful in preventing CHD.     

Cholesterol and heart disease in older persons and women. Review of an NHLBI workshop.

The value of serum total cholesterol measurement in predicting coronary heart disease (CHD) is well established in middle-aged men, but has been questioned in middle-aged women and older people of both sexes. To address this, the most recent follow-up data from 25 populations in 22 US and international cohort studies were presented and analyzed at a recent National Heart, Lung, and Blood Institute (NHLBI) workshop. Crude relative and absolute excess risks of fatal CHD were determined for individual studies and pooled across studies to determine pooled risk estimates. Serum total cholesterol and low-density-lipoprotein (LDL) cholesterol levels predicted fatal CHD in middle-aged (< 65 years) and older (> or = 65 years) men and women, though the strength and consistency of these relationships in older women were diminished. High-density-lipoprotein (HDL) cholesterol levels inversely predicted CHD in middle-aged men and women and in older women, but not in older men. Data for minority groups and for overseas populations were similar to those for white people in the United States. Relative risk estimates were generally lower for older than for middle-aged subjects, but absolute excess risk was greater. Older people and middle-aged women with elevated cholesterol levels are clearly at increased risk of coronary disease; whether this risk can be modified by dietary or drug therapy, and at what level intervention is appropriate, must not be determined.     

Low serum lycopene concentration is associated with an excess incidence of acute coronary events and stroke: the Kuopio Ischaemic Heart Disease Risk Factor Study.

A number of epidemiological studies have shown an association between beta-carotene and the risk of cardiovascular diseases, whereas only a few studies are available concerning the association of lycopene with the risk of coronary events, and no studies have been undertaken concerning lycopene and stroke. Thus, we tested the hypothesis that low serum levels of lycopene are associated with increased risk of acute coronary events and stroke in middle-aged men previously free of CHD and stroke. The subjects were 725 men aged 46-64 years examined in 1991-3 in the Kuopio Ischaemic Heart Disease Risk Factor Study. Forty-one men had either a fatal or a non-fatal acute coronary event or a stroke by December 1997. In a Cox' proportional hazard's model adjusting for examination years, age, systolic blood pressure and three nutritional factors (serum folate, beta-carotene and plasma vitamin C), men in the lowest quarter of serum lycopene levels (< or =0.07 micromol/l) had a 3.3-fold (95 % CI 1.7, 6.4, risk of acute coronary events or stroke compared with the others. Our study suggests that a low serum level of lycopene is associated with an increased risk of atherosclerotic vascular events in middle-aged men previously free of CHD and stroke.     

Fish and shellfish consumption in relation to death from myocardial infarction among men in Shanghai, China.

Between 1986 and 1989, 18,244 men aged 45-64 years in Shanghai, China, participated in a prospective study of diet and cancer. All participants completed an in-person, structured interview and provided blood and urine samples. As of September 1, 1998, 113 deaths from acute myocardial infarction were identified. After analyses were adjusted for age, total energy intake, and known cardiovascular disease risk factors, men who consumed >or=200 g of fish/shellfish per week had a relative risk of 0.41 (95% confidence interval: 0.22, 0.78) for fatal acute myocardial infarction compared with men consuming <50 g per week. Similarly, dietary intake of n-3 fatty acids derived from seafood also was significantly associated with reduced mortality from myocardial infarction. Neither dietary seafood nor n-3 fatty acid intake was associated with a reduced risk of death from stroke or ischemic heart disease other than acute myocardial infarction. However, approximately a 20% reduction in total mortality associated with weekly fish/shellfish intake was observed in the study population (relative risk = 0.79, 95% confidence interval: 0.69, 0.91). These prospective data suggest that eating fish and shellfish weekly reduces the risk of fatal myocardial infarction in middle-aged and older men in Shanghai, China.     

Association of visceral adipose tissue with incident myocardial infarction in older men and women: the Health, Aging and Body Composition Study

Assessment of body fat distribution, particularly visceral adipose tissue, may be important for accurate risk evaluation for cardiovascular disease in the elderly. This 1997-1998 US study examined the association of incident myocardial infarction (MI) with total adiposity (body mass index and fat mass) and body fat distribution (waist-to-thigh ratio, waist circumference, visceral and subcutaneous adipose tissue) in well-functioning men (n = 1,116) and women (n = 1,387) aged 70-79 years enrolled in the Health, Aging and Body Composition Study. There were 116 MI events (71 in men, 45 in women) during an average follow-up time of 4.6 (standard deviation, 0.9) years. No association was found between incident MI and the adiposity or fat distribution variables for men. For women, visceral adipose tissue was an independent predictor of MI (hazard ratio = 1.67, 95% confidence interval: 1.28, 2.17 per standard-deviation increase; p < 0.001). No association was found between body mass index or total fat mass and MI events in women. The association of visceral adipose tissue with MI in women was independent of high density lipoprotein cholesterol, interleukin-6 concentration, hypertension, and diabetes (hazard ratio = 1.79, 95% confidence interval: 1.24, 2.58 per standard-deviation increase; p < 0.01). The amount of adipose tissue stored in the intraabdominal cavity is an important, independent risk factor for MI in well-functioning, elderly women.     

The metabolic syndrome and the impact of diabetes on coronary heart disease mortality in women and men: the San Antonio Heart Study

PURPOSE: An explanation for the differential impact of diabetes on coronary heart disease (CHD) mortality in men and women is that diabetes and cardiovascular disease (CVD) share a common antecedent that differentially affects men and women. In the San Antonio Heart Study we examined the relationship between gender, the metabolic syndrome defined by the National Cholesterol Education Program (NCEP-MetS) and diabetes and their ability to predict CHD mortality. METHODS: Over 15.5 years, 4996 men and women 25 to 64 years of age experienced 254 cardiovascular deaths, including 121 from CHD (International Classification of Diseases, Ninth Revision codes 410-414). RESULTS: At baseline, NCEP-MetS occurred more often in men than in women among those with normal glucose levels (12.3% vs. 9.7%, p < 0.05), but less often in men than in women among those with diabetes (65.7% vs. 74.4%, p < 0.05). Adjusted for age, ethnic group, and a history of CVD, relative to women with neither diabetes nor NCEP-MetS, women with both had a 14-fold (hazard ratio [HR] = 14.3 [95% confidence interval: 6.62, 30.7]) increased risk of CHD mortality, whereas men had only a 4-fold (HR = 4.21 (95% confidence interval: 2.32, 7.65]) increased risk, respectively. CONCLUSION: When diabetes occurred with NCEP-MetS, gender was a strong modifier of the joint effect of diabetes and NCEP-MetS on CHD mortality.     

Low bone mineral density, coronary heart disease, and stroke mortality in men and women: the Third National Health and Nutrition Examination Survey

PURPOSE: The aim of this study is to determine the long-term association of bone mineral density and cardiovascular disease mortality. METHODS: The data used are from the Third National Health and Nutrition Examination Survey (NHANES III), a nationally representative sample of noninstitutionalized civilians. A cohort of white, black, and Mexican-American persons ages 50 years and older at baseline (1988-1994) was followed through 2000 for coronary heart disease (CHD; n = 4690) and stroke mortality (n = 5272) using the NHANES III Linked Mortality File. RESULTS: Death certificates were used to identify 369 CHD and 166 stroke deaths. Results were evaluated to determine the relative risk of CHD or stroke per one standard deviation lower bone mineral density after adjusting for multiple risk factors. In Cox proportional hazards models, risk of CHD death and risk of stroke death were not associated with low bone mineral density among men. For women, no significant associations were found for stroke (relative risk, 1.34; 95% confidence interval, 0.86-2.07, p = 0.20) or CHD (relative risk, 1.26; 95% confidence interval, 0.88, 1.80; p = 0.21). CONCLUSIONS: Low bone mineral density was not associated with risk of cardiovascular disease in men. Among women with low bone mineral density, risk of CHD and stroke were elevated, but no significant associations were found.     

Does cigarette smoking have an independent effect on coronary heart disease incidence in the elderly?

In order to evaluate the effects of cigarette smoking on coronary heart disease (CHD) in elderly persons in the Honolulu Heart Program, 1,394 men between ages 65 and 74 were followed during an average 12-year period for new cases of nonfatal myocardial infarction and fatal CHD. Incidence rates increased progressively in individuals classified at baseline as never, former, and current smokers, respectively. The absolute excess risk associated with cigarette smoking was nearly twice as high in elderly compared with middle-aged men.     

Serum ferritin and death from all causes and cardiovascular disease: the NHANES II Mortality Study. National Health and Nutrition Examination Study

PURPOSE: The purpose of this study was to assess the association between serum ferritin and death from all causes, cardiovascular diseases (CVD), CHD and myocardial infarction (MI). Positive body iron stores have been proposed as a risk factor for coronary heart disease (CHD). While most epidemiologic studies using serum ferritin and other measures of body iron stores have not found an association between iron and heart disease risk, the hypothesis remains controversial. As a result, we examined the relationship of serum ferritin, the principle blood measure of body iron stores, to risk of death in a cohort with a standardized exam and long follow-up. METHODS: The baseline data for this prospective cohort study were collected in 1976-1980 as part of the second National Health and Nutrition Examination Study (NHANES II) with mortality follow-up using the National Death Index (NDI) through December 31, 1992. The analytic sample (n = 1604) consisted of 128 black men, 658 white men, 100 black women and 718 white women 45-74 years of age at baseline who, based on self-reported data, were free of coronary heart disease at baseline and had no missing data. The main outcome measures were the relative risk of death for persons with serum ferritin levels: <50 microg/L; or 100-199 microg/L; or > or =200 microg/L was compared to persons with serum ferritin levels of 50-99 microg/L adjusted for possible confounding using the Cox proportional hazards model. RESULTS: Most of the deaths were among white men (n = 254) and women (n = 168). There were relatively few deaths among black men (n = 50) and too few in women (n = 23) to reliably model. The largest number of CVD (n = 119), CHD (n = 82), and MI (n = 49) deaths were in white men while there were 69 CVD, 45 CHD and 13 MI deaths in white women. Black men with a serum ferritin level of <50 microg/L had a significantly higher adjusted risk of death from all causes (RR = 3.1 with 95% confidence limits of 1.5-6.5). There were no other statistically significant associations for all causes mortality for the other three race/sex groups. Additionally, there were no statistically significant associations between serum ferritin and any of the cardiovascular endpoints for any of the groups. There was an apparent but nonsignificant u-shaped association between serum ferritin and all causes mortality in black men and between serum ferritin and CVD death in white women. However, in both cases very wide confidence limits preclude further interpretation. CONCLUSIONS: Overall, the results do not support the hypothesis that positive body iron stores, as measured by serum ferritin, are associated with an increased risk of CVD, CHD or MI death or between serum ferritin and all causes mortality. Most of the research to date with serum ferritin has been conducted in European men or in European American men. Our results are consistent with the primarily negative results for that race/sex group. More research is needed in women and minority groups, including an explanation of why such an association would exist in these groups but not in white men before an association can be established in them.     

Magnesium intake and risk of coronary heart disease among men

OBJECTIVE: Our aim in this study was to assess the relationship between magnesium intake and risk of coronary heart disease (CHD) among men. METHODS: A total of 39,633 men in the Health Professionals Follow-up Study who returned a dietary questionnaire in 1986 were followed up for 12 years. Intakes of magnesium, zinc and potassium and other nutrients were assessed in 1986, 1990 and 1994. Total CHD incidence (nonfatal myocardial infarction (MI) and fatal CHD) was ascertained by biennial questionnaire and mortality surveillance confirmed by medical record review. Standard CHD risk factors were recorded biennially. RESULTS: During 12 years of follow-up (414,285 person-years), we documented 1,449 cases of total CHD (1,021 non-fatal MI cases, and 428 fatal CHD). The age-adjusted relative risk (RR) of developing CHD in the highest quintile (median intake = 457 mg/day) compared with the lowest quintile (median intake = 269 mg/day) was 0.73 (95% CI 0.62-0.87, p for trend <0.0001). After controlling for standard CHD risk factors and dietary factors, the RR for developing CHD among men in the highest total magnesium intake quintile compared with those in the lowest was 0.82 (95% CI 0.65-1.05, p for trend = 0.08). For supplemental magnesium intake, the RR comparing the highest quintile to non-supplement users was 0.77 (95% CI 0.56-1.06, p for trend = 0.14). CONCLUSIONS: These results suggest that intake of magnesium may have a modest inverse association with risk of CHD among men.     

Educational inequalities in the metabolic syndrome and coronary heart disease among middle-aged men and women

BACKGROUND: Previous studies have shown socioeconomic inequalities in the metabolic syndrome and coronary heart disease (CHD), but it is not known whether educational disparities in the metabolic syndrome explain educational inequalities in CHD. We investigated this question in a prospective study of middle-aged men and women. METHODS: Baseline data were collected in 1992 in Finland from 864 men and 1045 women aged 45-64 years without history of CHD. A total of 113 new CHD cases were identified by the end of 2001. Logistic and Cox regression models were used in data analysis. RESULTS: The metabolic syndrome defined by NCEP criteria was less prevalent in subjects with university education (21% in men and 14% in women) compared with basic level education (41% and 27%, respectively). Adjusting for health behavioural factors had only a slight effect on the educational gradient in the metabolic syndrome. An educational gradient in CHD incidence was clear [hazard ratio (HR) = 0.67 95% confidence interval (CI) 0.48-0.94, men and women combined]. Adjustment for the metabolic syndrome attenuated this gradient only slightly, but when individual components of the metabolic syndrome were included as covariates the attenuation was more substantial (HR = 0.73 95% CI 0.52-1.04). CONCLUSIONS: Educational differences in the metabolic syndrome and CHD incidence are clear. Metabolic risk factors explain the gradient in CHD incidence partly, but only when they are treated as independent risk factors. Screening for the metabolic syndrome alone is not sufficient to account for socioeconomic inequalities in cardiovascular disease.     

Sudden death and recurrent ischemic events after myocardial infarction in the community

As myocardial infarction (MI) hospital fatalities decline, survivors are candidates for recurrent events. However, little is known about morbidity after MI and how it may have changed over time. The authors examined the incidence of sudden cardiac death and recurrent ischemic events post-MI to test the hypothesis that it has declined over time. MIs were validated by using standardized criteria. Sudden cardiac death and recurrent ischemic events (recurrent MI or unstable angina) were identified through Olmsted County, Minnesota, community medical records and their association with time examined after adjustment for age, sex, and comorbidity. Between 1979 and 1998, 2,277 MIs occurred (57% in men; mean age, 67 (standard deviation, 14) years). After 3 years, the event-free survival rate was 94% (95% confidence interval: 93, 95) for sudden cardiac death and 56% (95% confidence interval: 54, 58) for recurrent ischemic events. Both outcomes were more frequent with older age and greater comorbidity. The temporal decline in both events was of similar magnitude; for an MI occurring in 1998 versus 1979, risk of subsequent recurrent ischemic events or sudden cardiac death declined by 24% (relative risk = 0.76, 95% confidence interval: 0.63, 0.93). Thus, in the community, recurrent ischemic events are frequent post-MI, while sudden cardiac death is less common. Their incidence declined over time, supporting the notion that contemporary treatments effectively improve outcomes after MI.