Distribution of the global cardiovascular risk in the Italian population: results from the cardiovascular epidemiologic observatory]

BACKGROUND: The aim of this study was to assess the 10-year cardiovascular risk categories using risk chart, recently set up by the National Institute of Health in the population examined by the Cardiovascular Epidemiologic Observatory. METHODS: 3745 men and 3664 women aged 40-69 years were classified into five risk categories (< 5 %; 5-10%; 10-15%; 15-20%; > or = 20%) taking into account age, smoking habit, history of diabetes, systolic blood pressure, serum cholesterol and excluding those already under treatment for hypertension and hypercholesterolaemia or experienced a previous major cardiovascular event (1937 persons: 955 men, 982 women). RESULTS: Proportion of people estimated at risk in 10 years > or = 20% is minimal in the youngest age range, increases in adulthood, duplicates in smokers and is higher in diabetics. In non-diabetic men that proportion varies between 3.4% in non-smokers and 5.6% in smokers. All women at risk are already under specific treatment. CONCLUSIONS: Cardiovascular Epidemiologic Observatory data allowed to assess the expected proportion of individuals at risk in 10 years > or = 20%. Besides attention to high-risk individuals, preventive measures supporting a healthier lifestyle in the general population must be adopted, considering that it will produce the greatest number of events.     

Coronary risk versus cardiovascular risk for treatment decisions in mild hypertension

BACKGROUND: British guidelines recommend treatment for mild hypertension at a cardiovascular (CVD) risk threshold of 20% over 10 years. However, treatment is targeted at the equivalent coronary (CHD) risk of 15% over 10 years. We examined the relationship between CHD and CVD risk in men and women with mild hypertension and assessed the accuracy of using a 10-year CHD risk threshold of 15% to identify patients at a 10-year CVD risk > or = 20%. DESIGN: Cross-sectional survey of England in 1998. METHODS: We identified 5588 subjects aged 35-74 years free of cardiovascular disease with complete data for risk assessment. Of these, 1364 (24.4%) had mild hypertension (systolic pressure 140-159 mmHg or diastolic pressure 90-99 mmHg). The Framingham functions were used to estimate CHD and CVD event risk for each individual. RESULTS: At a 10-year CHD risk of 15%, the corresponding 10-year CVD risk for men and women, respectively was 20% and 21% in those aged < 55 years, and 24% and 25% in those aged > or = 55 years. Using a 10-year CHD risk threshold of 15% to identify patients at a 10-year CVD risk > or = 20% had high specificity (>96%) in all four groups. For men and women respectively, the sensitivity was 73% (62-84%) and 62% (35-88%) in younger subjects, and 89% (85-93%) and 47% (38-56%) in older subjects. CONCLUSION: Using a 10-year CHD risk of 15% to target patients at a 10-year CVD risk > or = 20% was reasonably accurate for men but missed about 50% of women eligible for antihypertensive treatment.     

Sex and time differences in the associations of non-high-density lipoprotein cholesterol versus other lipid and lipoprotein factors in the prediction of cardiovascular death (The Rancho Bernardo Study)

Non-high-density lipoprotein (HDL) cholesterol (total cholesterol [TC] minus HDL cholesterol) has been suggested as the preferred lipid fraction to predict cardiovascular disease. We compared the ability of lipids, lipoproteins, the ratio of total to HDL cholesterol (TC/HDL), and non-HDL cholesterol to predict fatal coronary heart disease (CHD) and cardiovascular disease in 1,386 women and 1,094 men (mean age 69 years). After 10 years, there were more deaths in men (n = 310) than women (n = 268), but the proportions of deaths attributed to CHD (23% and 25%, respectively) and cardiovascular disease (48% and 47%) were similar. In men, age-adjusted values for non-HDL cholesterol, TC/HDL ratio, and triglycerides each predicted a significantly increased risk of CHD and cardiovascular disease; none of these associations was independent of pack-years of smoking, systolic blood pressure, fasting plasma glucose, body mass index, and physical activity. In women, age-adjusted non-HDL cholesterol levels did not predict CHD or cardiovascular disease events before or after adjusting for these covariates and for estrogen replacement therapy. In women, only the ratio of TC to HDL cholesterol predicted CHD and cardiovascular disease deaths independent of estrogen use and other risk factors. Observed associations were sensitive to time, being evident in women at 3 and 5 years, and lost thereafter, but not apparent before 10 years in men. Thus, non-HDL cholesterol is not superior to individual lipids, lipoproteins, or their ratios in the prediction of cardiovascular death in older adults.     

Lipoprotein(a) associated with coronary artery disease in older women: age and gender analysis

BACKGROUND: Lipoprotein (a) has been associated with increased coronary artery disease (CAD) risk in men, but relatively little data exists in women. While age influences the cardiovascular risk associated with Lp(a) in men, little is known about this phenomenon in women. The impact of gender on Lp(a) has not been fully studied in an ongoing clinical practice. METHODS AND RESULTS: Baseline Lp(a) values were measured in 918 CAD and 829 non-CAD patients (603 females, 1144 males) entering an outpatient prevention clinic. The age-specific association of elevated Lp(a) (> 30 mg/dl) with CAD was examined after adjustment for traditional risk factors. Lp(a) was a significant risk factor (OR = 1.9, CI, 1.4-2.6) in men and women (OR = 1.9, CI 1.3-2.9). In men age < or = 55 years the odds ratio for increased cardiovascular risk in high vs low Lp(a) was 2.5 (CI 1.6-3.9). In men < or = 55, CAD increased from 32 to 61% as Lp(a) progressively rose from < or = 5 to > or = 45 mg/dl (P value for trend < 0.001). No significant increase was observed in men > 55 years (OR = 1.3, CI 0.9-2.1). In women < or = 55 years, the risk of CAD increased from 22 to 35% (OR 1.6, CI 0.8-3.2), and increased from 38 to 63% in women > 55 (OR 2.1, CI 1.3-3.5). Further, of high-risk patients (men < or = 55 and women > 55 years) with an Lp(a) in the range of 20-44 mg/dl (third quartile), younger men showed a greater incidence of CAD (51%) than older women (43%). Both genders revealed substantial risk when the Lp(a) values were above 45 mg/dl. (OR = 3.7, CI = 2.0-6.8 in younger men; OR = 3.3, CI = 1.6-6.6 in older women). CONCLUSIONS: In this cross sectional study of both men and women, elevated Lp(a) was associated with a significantly increased risk of CAD in men and women. While we corroborate previous reports on the lack of association in older men, the determination of an enhanced Lp(a)-related risk in older women was new and unanticipated. Further, in this population of high risk patients, substantial cardiovascular risk appeared to be represented by higher concentrations of Lp(a) in women than observed in men.     

Proteinuria as a risk factor for cardiovascular disease and mortality in older people: a prospective study

BACKGROUND: The prognostic significance of proteinuria in older people is not well defined. We examined the associations between proteinuria and incident coronary heart disease, cardiovascular mortality, and all-cause mortality in older people.SUBJECTS AND METHODS: Casual dipstick proteinuria was determined in 1,045 men (mean [+/- SD] age 68 +/- 7 years) and 1,541 women (mean age 69 +/- 7 years) attending the 15th biennial examination of the Framingham Heart Study. Participants were divided by grade of proteinuria: none (85.3%), trace (10.2%), and greater-than-trace (4.5%). Cox proportional hazards analyses were used to determine the relations of baseline proteinuria to the specified outcomes, adjusting for other risk factors, including serum creatinine level.RESULTS: During 17 years of follow-up, there were 455 coronary heart disease events, 412 cardiovascular disease deaths, and 1,214 deaths. In men, baseline proteinuria was associated with all-cause mortality (hazards ratio [HR] = 1.3, 95% confidence interval [CI] 1.0 to 1.7 for trace proteinuria; HR = 1.3, 95% CI 1.0 to 1.8 for greater-than-trace proteinuria; P for trend = 0.02). In women, trace proteinuria was associated with cardiovascular disease death (HR = 1. 6, 95% CI 1.1 to 2.4), and all-cause mortality (HR = 1.4, 95% CI 1.1 to 1.7).CONCLUSION: Proteinuria is a significant, although relatively weak, risk factor for all-cause mortality in men and women, and for cardiovascular disease mortality in women.     

A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/Paisley study

PURPOSE: To describe the effect of atrial fibrillation on long-term morbidity and mortality. SUBJECTS AND METHODS: The Renfrew/Paisley Study surveyed 7052 men and 8354 women aged 45-64 years between 1972 and 1976. All hospitalizations and deaths occurring during the subsequent 20 years were analyzed by the presence or absence of atrial fibrillation at baseline. Lone atrial fibrillation was defined in the absence of other cardiovascular signs or symptoms. Cox proportional hazards models were used to adjust for age and cardiovascular conditions. RESULTS: After 20 years, 42 (89%) of the 47 women with atrial fibrillation had a cardiovascular event (death or hospitalization), compared with 2276 (27%) of the 8307 women without this arrhythmia. Among men, 35 (66%) of 53 with atrial fibrillation had an event, compared with 3151 (45%) of 6999 without atrial fibrillation. In women, atrial fibrillation was an independent predictor of cardiovascular events (rate ratio [RR] = 3.0; 95% confidence interval [CI]: 2.1-4.2), fatal or nonfatal strokes (RR = 3.2; 95% CI: 1.0-5.0), and heart failure (RR = 3.4; 95% CI: 1.9-6.2). The rate ratios among men were 1.8 (95% CI: 1.3-2.5) for cardiovascular events, 2.5 (95% CI: 1.3-4.8) for strokes, and 3.4 (95% CI: 1.7-6.8) for heart failure. Atrial fibrillation was an independent predictor of all-cause mortality in women (RR = 2.2; 95% CI: 1.5-3.2) and men (RR = 1.5; 95% CI: 1.2-2.2). However, lone atrial fibrillation (which occurred in 15 subjects) was not associated with a statistically significant increase in either cardiovascular events (RR = 1.5; 95% CI: 0.6-3.6) or mortality (RR = 1.8; 95% CI: 0.9-3.8). CONCLUSIONS: Atrial fibrillation is associated with an increased long-term risk of stroke, heart failure, and all-cause mortality, especially in women.     

Relationship of subclinical coronary atherosclerosis and National Cholesterol Education Panel guidelines in asymptomatic Brazilian men

BACKGROUND AND OBJECTIVE: Coronary heart disease (CHD) is the leading cause of death worldwide including Brazil. Improved precision in detecting early coronary disease may aid in more targeted preventive therapy. The National Cholesterol Education Program (NCEP) provides guidelines for determining the aggressiveness of primary prevention strategies including lipid lowering based on Framingham risk equation. Identification of subclinical atherosclerosis and coronary plaque burden is a step towards identifying high-risk individuals. This investigation was designed to determine how the updated NCEP guidelines classify asymptomatic individuals with presence of any as well as advanced CACS (coronary artery calcium score), a powerful intermediary for CHD events, in asymptomatic Brazilian men. METHODS AND RESULTS: Five hundred forty-six asymptomatic Brazilian men (mean age: 46+/-7 years) presented to a single electron beam tomography (EBT) facility in Sao Paulo. The study population was categorized into low risk (0-1 risk factors, n=166, 30%), intermediate risk (> or = 2 risk factors but < 10% risk of CHD over 10 years, n=150, 27%), moderately high risk (2 risk factors and 10-20% risk of hard CHD events in 10 years, n=147, 28%) and high-risk (> or = 2 risk factors and > 20% risk of hard CHD events in 10 years, n=83, 15%), respectively. In our study population, overall no CACS, mild CACS (1-99.9), moderate-severe CACS (> or = 100) were observed in 317 (58%), 160 (29%) and 69 (13%) men, respectively. Advanced calcification (CACS > or = 75th percentile for age) was present in 19% (n=104) men. Based on the LDL-C cutoffs recommended by the NCEP guidelines for initiation of lipid lowering, overall only 55% with CACS > or = 100 and 42% men with CACS > or = 75th percentile qualified for pharmacotherapy. As a result nearly half of individuals with CACS > or = 100 (45%) and CACS > or = 75th percentile (48%) missed eligibility for drug therapy. CONCLUSION: Our findings reveal the potential limitation of NCEP guidelines in identifying asymptomatic Brazilian men with significant coronary atherosclerosis who are potential candidates for aggressive primary prevention. Assessment of CACS may provide incremental value to global risk assessment in high-risk Brazilian men.     

Overweight and obesity as determinants of cardiovascular risk: the Framingham experience

BACKGROUND: To our knowledge, no single investigation concerning the long-term effects of overweight status on the risk for hypertension, hypercholesterolemia, diabetes mellitus, and cardiovascular sequelae has been reported. METHODS: Relations between categories of body mass index (BMI), cardiovascular disease risk factors, and vascular disease end points were examined prospectively in Framingham Heart Study participants aged 35 to 75 years, who were followed up to 44 years. The primary outcome was new cardiovascular disease, which included angina pectoris, myocardial infarction, coronary heart disease, or stroke. Analyses compared overweight (BMI [calculated as weight in kilograms divided by the square of height in meters], 25.0-29.9) and obese persons (BMI > or =30) to a referent group of normal-weight persons (BMI, 18.5-24.9). RESULTS: The age-adjusted relative risk (RR) for new hypertension was highly associated with overweight status (men: RR, 1.46; women: RR, 1.75). New hypercholesterolemia and diabetes mellitus were less highly associated with excess adiposity. The age-adjusted RR (confidence interval [CI]) for cardiovascular disease was increased among those who were overweight (men: 1.21 [1.05-1.40]; women: 1.20 [1.03-1.41]) and the obese (men: 1.46 [1.20-1.77]; women: 1.64 [1.37-1.98]). High population attributable risks were related to excess weight (BMI > or =25) for the outcomes hypertension (26% men; 28% women), angina pectoris (26% men; 22% women), and coronary heart disease (23% men; 15% women). CONCLUSIONS: The overweight category is associated with increased relative and population attributable risk for hypertension and cardiovascular sequelae. Interventions to reduce adiposity and avoid excess weight may have large effects on the development of risk factors and cardiovascular disease at an individual and population level.     

Relative validity of the 10-year cardiovascular risk estimate in a population cohort of the REGICOR study

Introduction and objectives

Cardiovascular risk screening requires accurate risk functions. The relative validity of the Framingham-based REGICOR adapted function is analyzed and the population distribution of cardiovascular 10-year cardiovascular events is described by risk group.

Methods

A population cohort of 3856 participants recruited between 1995 and 2000, aged 35 to 74 years from Girona without symptoms of cardiovascular diseases, was followed between 2006 and 2009. Standardized laboratory and blood pressure measurements, questionnaires, and case definitions were used. The follow-up combined cross-linkage of our databases with our regional mortality registry, reexamination, and telephone contact with participants. Coronary disease endpoints alone were considered.

Results

A total of 27 487 person-years were obtained (mean follow-up 7.1 years), and the follow-up was achieved in 97% of participants (120 coronary disease events). Validity was good: the regression coefficients estimated with the cohort data did not differ from those obtained in the original Framingham function. Function calibration was good: the observed incidence of cardiovascular events in the decile groups of risk did not differ from the function prediction (P = .127 in women, and P = .054 in men). The C statistic (discrimination) was 0.82 (95% confidence interval, 0.76-0.88) in women, and 0.78 (95% confidence interval, 0.73-0.83) in men. More than 50% of cardiovascular events occurred in participants whose 10-year risk was 5% to 14.9%.

Conclusions

The studied function accurately predicts coronary disease events at 10 years. Risk stratification could be simplified in 4 groups: low (<5%), moderate (5%-9.9%), high (10%-14.9%) and very high (≥15%).Full English text available from: www.revespcardiol.org     

Middle age cardiovascular risk factors and abdominal aortic aneurysm in older age

Few prospective studies have examined associations between major cardiovascular risk factors and occurrence of abdominal aortic aneurysm; findings from cross-sectional studies are inconsistent. This long-term population-based study assessed relationships of major risk factors in middle-age to clinical nonfatal plus fatal abdominal aortic aneurysm in older-age in the Chicago Heart Association Detection Project in Industry cohort--10 574 men and 8700 women baseline ages 40 to 64 years screened for risk factors in 1967-1973 at workplaces. With average follow-up of 30 years and clinical cases identified from Medicare records and death certificates, risk factor relationships to abdominal aortic aneurysm occurrence were assessed by Cox regression. There were among men 309 cases and among women, 109--most from Medicare records. Most findings were qualitatively similar for men and women. In multivariate analyses (5 models), hazard ratios for abdominal aortic aneurysm were significantly greater for men than women (> or =1.97), with older age (> or =1.63/5 years), higher serum cholesterol (> or =1.30/40.0 mg/dL), cigarettes/d (> or =2.43/20 cigarettes), past smoking (> or =1.41), height (> or =1.17/7 cm), evidence of adverse blood pressure (hazard ratio 1.10/20 mm Hg higher systolic pressure, 1.12 to 1.14/12 mm Hg higher diastolic pressure, 1.87 with history of treated hypertension). It is concluded that major cardiovascular risk factors--serum cholesterol, smoking, and blood pressure--in middle age relate significantly to risk of abdominal aortic aneurysm in persons surviving into older age.     

Combined cardiovascular risk factors and outcome: NIPPON DATA80, 1980-1994.

BACKGROUND: To examine the prognostic significance of the high-risk group with combined cardiovascular risk factors in the Japanese, we analyzed the relationship between the high-risk group with combined risks and coronary heart disease (CHD) and stroke mortality using the NIPPON DATA80 database. METHODS AND RESULTS: At baseline in 1980, those of age>or=30 years were randomly selected and 4,144 men and 5,318 women without CHD and/or stroke at baseline were followed for 14 years. The cutoff values for risk components obtained heuristically by Cox analysis were hypertension (systolic>or=130, or diastolic>or=85 mmHg, or on antihypertensive drugs), hypercholesterolemia (total cholesterol>or=200 mg/dl), hyperglycemia (>or=130 mg/dl, or self-reported diabetes) and obesity (body mass index>or=27 kg/m2). Subjects were divided into 3 groups (0, 1-2 and 3-4 risks). Compared with those men in the risk 0 group, the hazard ratios in men in the risk 3-4 for CHD mortality was 8.04 (95% confidence interval: 1.03-62.6), and the stroke mortality was 5.06 (1.53-16.7). In women, no statistically significant difference was found due to a lesser number of events. CONCLUSION: The high-risk group with combined risk factors is important risk for Japanese men.     

The joint associations of occupational, commuting, and leisure-time physical activity, and the Framingham risk score on the 10-year risk of coronary heart disease.

AIMS: To determine joint associations of different kinds of physical activity and the Framingham risk score (FRS) with the 10-year risk of coronary heart disease (CHD) events. METHODS AND RESULTS: Study cohorts included 41 053 Finnish participants aged 25-64 years without history of CHD and stroke. The multivariable-adjusted 10-year hazard ratios (HRs) of coronary events associated with low, moderate, and high occupational physical activity were 1.00, 0.66, and 0.74 (Ptrend<0.001) for men, and 1.00, 0.53, and 0.58 (Ptrend<0.001) for women, respectively. The multivariable-adjusted 10-year HRs of coronary events associated with low, moderate, and high leisure-time physical activity were 1.00, 0.97, and 0.66 (Ptrend=0.002) for men, and 1.00, 0.74, and 0.54 (Ptrend=0.003) for women, respectively. Active commuting had a significant inverse association with 10-year risk of coronary events in women only. The FRS predicted 10-year risk of coronary events among both men and women. The protective effects of occupational, commuting, or leisure-time physical activity were consistent in subjects with a very low (<6%), low (6-9%), intermediate (10-19%), or high (>or=20%) risk of the FRS. CONCLUSION: Moderate or high levels of occupational or leisure-time physical activity among both men and women, and daily walking or cycling to and from work among women are associated with a reduced 10-year risk of CHD events. These favourable effects of physical activity on CHD risk are observed at all levels of CHD risk based on FRS assessment.     

Impact of sex, metabolic syndrome, and diabetes mellitus on cardiovascular events

Although cardiovascular events occur more frequently among patients with metabolic syndrome (MS) or diabetes mellitus (DM), the impact of gender is unclear. We aimed to determine the relation of MS and DM on cardiovascular events between men and women. The National Health Survey of 1992 provided information on outcomes for 3,414 Singaporeans aged 18 to 69 years without cardiovascular diseases. Definition of MS was based on the National Cholesterol Education Program criteria. Cardiovascular events included hospital admissions for coronary heart disease, stroke, and cardiovascular mortality. The proportion of subjects with MS was 12.4%. After 10 years, the annual cardiovascular event rates (per 1,000 person-years) for men without DM were 3.0 and 15.9 among subjects without and with MS, respectively, and the respective rates for men with DM were 22.5 and 21.4. The corresponding rates for women were 0.9, 3.7, 5.3, and 21.5, respectively. Among nondiabetic subjects, cardiovascular events occurred more frequently among men than women among subjects with MS (adjusted hazard ratios [HRs] 4.71, 95% confidence interval [CI] 1.56 to 14.2) and those without MS (HR 3.35, 95% CI 1.78 to 6.31). Among patients with DM, cardiovascular events occurred more commonly among men than women without MS (HR 6.04, 95% CI 1.43 to 25.6). Rates for cardiovascular events were comparable between men and women with DM and MS (HR 0.98, 95% CI 0.48 to 1.99). In conclusion, the adverse impact of MS or DM was greater among men, and the presence of both conditions increases the risk substantially for cardiovascular events among women.     

Impact of metabolic syndrome on atherosclerotic burden and cardiovascular prognosis

Patients with metabolic syndrome (MS) are at increased risk of cardiovascular atherosclerosis. The aim of this study was to evaluate the impact of MS on cardiovascular prognosis in context with atherosclerotic burden. A total of 811 patients with coronary heart disease (CHD) were included and carotid and leg arteries were examined using sonographic methods. Patients with low (CHD only, n = 428, 52.8%) or high atherosclerotic burden (CHD and peripheral atherosclerosis, n=383, 47.2%) were compared. Patients with >or=3 of the following criteria: triglycerides>or=150 mg/dl, high-density lipoprotein cholesterol<40 mg/dl (men) and <50 mg/dl (women), body mass index>30 kg/m2, blood pressure>or=130/85 mm Hg, and fasting glucose>or=100 mg/dl were defined as having MS (n=349, 43.0%). Follow-up data (median 6.7 years) were available for 807 patients (99.5%), and 175 patients (21.7%) experienced cardiovascular events (myocardial infarction, death, and stroke). The presence of MS significantly increased cardiovascular events in patients with low and high atherosclerotic burden (low: MS yes 21.2%, MS no 12.9%, p=0.02; high: MS yes 34.3%, MS no 26.5%, p=0.01). MS could be identified as an independent predictor for cardiovascular events in all patients (hazard ratio 1.7, 95% confidence interval 1.3 to 2.3, p<0.0001, adjusted) and patients with high atherosclerotic burden in particular (hazard ratio 1.8, 95% confidence interval 1.2 to 2.6, p=0.005, adjusted). In conclusion, MS markedly worsens the long-term prognosis of patients with both low and high atherosclerotic burden. Moreover, patients with high atherosclerotic burden and MS should be considered a high-risk population and treated accordingly.     

Risk factors associated with newly diagnosed high blood pressure in men and women

BACKGROUND: Hypertension is a major risk factor for cardiovascular diseases. Early diagnosis and prevention of hypertension are of great importance in reducing overall mortality. The objective was to determine which potential risk factors are associated with newly diagnosed high blood pressure in women and men. METHODS: This study is part of a population-based, cross-sectional study including 4,228 women and men aged 60 years in Stockholm County, Sweden. Newly diagnosed high blood pressure was defined as systolic and/or diastolic blood pressure exceeding 140/90 measured on one occasion. Subjects with known hypertension were excluded, leaving 3,156 individuals. RESULTS: Waist circumference > or =95 cm (quintiles 3-5) in men and > or =88.5 cm (quintiles 4-5) in women was associated with newly diagnosed high blood pressure. Secondary school was a protective factor in men (odds ratio (OR), men = 0.73, 95% confidence interval (CI) = 0.54-0.99) and university education was protective in both men (OR = 0.66, 95% CI = 0.52-0.85) and women (OR = 0.45, 95% CI = 0.34-0.59). Regular physical activity was negatively associated in women (OR = 0.77, 95% CI = 0.61-0.99), and high alcohol consumption (>30 g/day) was positively associated in men (OR = 1.60, 95% CI = 1.22-2.09). Women were negatively associated with newly diagnosed high blood pressure (OR = 0.50, 95% CI = 0.41-0.61). An interaction between college/university and gender was found in multivariate analysis (OR = 0.67, 95% CI = 0.47-0.97). CONCLUSION: Gender differences in risk profile for newly diagnosed high blood pressure might explain part of the differences in hypertension found between men and women. These findings should be considered when planning preventive actions against hypertension at the community level.     

Action levels for obesity treatment in 40 to 42-y-old men and women compared with action levels for prevention of coronary heart disease.

BACKGROUND: Guidelines for treating overweight and obesity have been suggested by the World Health Organization and other expert groups. We asked whether most men and women targeted in obesity guidelines would already be included in existing clinical recommendations for the prevention of coronary heart disease (CHD) or whether a new group of patients would be added to current workloads. SUBJECTS AND METHODS: In 1997 the Norwegian National Health Screening Service examined CHD risk factors in subjects aged 40-42 y living in three counties. We studied 6911 men and 7992 women who did not report treatment for diabetes, hypertension or the presence of cardiovascular disease. Estimated 10 y risk of CHD was calculated using the Framingham equation. RESULTS: The prevalence of single risk factors (systolic blood pressure > or =160 mmHg, diastolic blood pressure > or =95 mmHg, total cholesterol level > or =7.8 mmol/l and nonfasting glucose > or =11.1 mmol/l) ranged between 0 and 11% among subjects with body mass index > or =25 kg/m2. Adding low HDL cholesterol (<1.0 mmol/l for men, <1.1 mmol/l for women) and 10 y risk CHD risk to the classical risk factors increased prevalence to 16-50% (one or more risk factors or 10 y risk > or =10%). Sensitivities and specificities of using body mass index (BMI) or BMI and waist circumference as a screen for elevated CHD risk ranged between 22 and 91%. Screening for 10 y CHD risk of > or =10% or one or more risk factors among men and screening for one or more risk factors among women gave positive predictive values of 19-50%; however, the positive predictive value of screening for 10 y CHD risk of > or =10% was only 1-2% among women. Compared with men with BMI<30 kg/m2 or waist circumference <102 cm, those with measurements equal to or above these levels had statistically significantly higher adjusted odds ratios of elevated CHD risk (1.49, 95% CI 1.24-1.79 and 1.48, 95% CI 1.22-1.80, respectively); these associations were not observed among women. CONCLUSION: Using BMI and waist circumference to screen for CHD risk yields low positive prediction values, thus doubling the number of men and adding even more to the number of women seen by the practitioner for prevention of CHD.     

Obesity and cardiovascular events in patients with established coronary disease.

AIMS: To explore the association between obesity and major adverse coronary events (MACE) in patients with established coronary artery disease (CAD). METHODS AND RESULTS: The Prevention of Events with Angiotensin Converting Enzyme-Inhibition (PEACE) Trial randomized 8290 patients with stable CAD and left ventricular (LV) ejection fraction (EF) (LVEF) > or =0.40 to trandolapril or placebo and followed them for a median of 4.8 years. In PEACE patients who were non-diabetic at baseline (5693 men and 1171 women), we used proportional hazards models to conduct a post hoc analysis to examine whether obesity, defined as a body mass index (BMI) > or =30 kg/m(2), is an independent risk factor for the composite endpoint of MACE, defined as cardiovascular death, non-fatal myocardial infarction, coronary revascularization, or stroke. The analysis was conducted separately for men and women. The baseline prevalence of obesity was 28.5% in men and 28.9% in women. After adjusting for significant confounders, obesity was associated with MACE in men [hazard ratio (HR) = 1.28, 95% CI 1.13-1.46, P < 0.01], but not in women (HR = 0.96, 95% CI 0.70-1.31, P = 0.77). Further categorization of BMI showed a J-shaped association between BMI and MACE in the men, and no association in the women. CONCLUSION: In the presence of established CAD, obesity is associated with risk for MACE in men, but there is no support of an association in women. This finding requires further evaluation.     

Influence of high-density lipoprotein cholesterol and rheological factors on the sex difference in cardiovascular disease

BACKGROUND: It is well established that the incidence of cardiovascular disease among men is higher than that among women. OBJECTIVE: To determine whether differences between men and women in terms of a range of conventional and rheological risk factors could explain this sex difference. DESIGN: This was a population-based cohort study (the Edinburgh Artery Study). METHODS: Men and women aged 55-74 years (n = 1592) were selected at random from the general population of Edinburgh and followed up for 5 years. Baseline cardiovascular risk factors were measured and related to incidence of disease among men and women. RESULTS: Men had higher levels of cigarette smoking, haematocrit and blood viscosity and lower levels of low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol and plasma fibrinogen than did women. The incidences of cardiovascular events among men and women were 48.3 and 26.1 per 1000 person-years, respectively. Adjustment for level of HDL cholesterol reduced the male:female ratio for sex-specific incidence rates of cardiovascular events from 1.80 [95% confidence interval (CI) 1.43-2.27] to 1.34 (95% CI 1.04-1.73). This reduction was partially reversed after further adjustment for the other cardiovascular risk factors. The impact of blood viscosity, plasma viscosity and plasma level of fibrinogen on the risk of cardiovascular disease was higher for men than it was for women (multivariate relative risk for blood viscosity were 1.24, 95% CI 1.08-1.43, for men and 0.81, 95% CI 0.61-1.06, for women). CONCLUSIONS: Levels of HDL cholesterol levels in women being higher than those in men may explain some, but not all, of the sex difference in incidence of cardiovascular disease. Greater susceptibility of men to rheological factors might also be important.     

Impaired fasting glucose and recurrent cardiovascular disease among survivors of a first acute myocardial infarction: Evidence of a sex difference? The Western New York experience

Background and aims

There is little epidemiological evidence regarding the association of impaired glucose metabolism with recurrent cardiovascular events. We therefore examined potential sex differences in the effect of impaired fasting glucose (IFG) on recurrent cardiovascular disease (CVD) in a community-based study of survivors of a first acute myocardial infarction (MI).

Methods and results

This report focuses on 1226 incident MI cases (28.4% women) discharged alive from area hospitals in the Western New York Acute MI Study (1996-2004). Deaths and underlying cause of death were determined via query of the National Death Index (Plus) Retrieval Program with follow-up through December 31, 2004. Outcomes reported included fatal or non-fatal coronary heart disease (CHD) or coronary revascularization surgery and total stroke. Traditional CHD risk factors and other explanatory variables were determined by clinical examination after the first acute event. Impaired fasting glucose was defined as fasting blood glucose between 100 and 125 mg/dl. During a mean follow-up of 4.5 years, there were 91 recurrent events (26.1%) in women and 173 recurrent events (19.7%) in men. After multivariable adjustment, the hazard ratios for recurrent cardiovascular events were 1.96 (95% CI: 1.15-3.16) and 2.59 (1.56-4.30) in women with IFG and with diabetes, respectively, compared to normoglycemic women. Among men, neither IFG nor diabetes was independently related to risk of recurrence.

Conclusions

In this study, IFG was a strong risk factor for recurrent cardiovascular events only among women. These results suggest that increased cardiovascular risk in MI survivors begins at lower glucose levels in women than men.     

Hypertension as a risk factor for cardiovascular morbidity and mortality in an elderly German population; the prospective STEPHY II study. Starnberg Study on Epidemiology of Parkinsonism and Hypertension in the Elderly.

AIM: To prospectively study the relationship between blood pressure levels and subsequent cardiovascular morbidity and mortality in a population aged 65 years and older. METHODS: Participants of the 1992 baseline survey of the population-based Starnberg Study on Epidemiology of Parkinsonism and Hypertension in the Elderly (STEPHY, 394 men and 588 women above age 65) were followed up for 3 years. Total mortality was assessed by official death data. Cardiovascular morbidity, that is, the occurrence of non-fatal events (new cases of acute myocardial infarction, angina pectoris, stroke, and heart failure) could be assessed in 681 of the 863 survivors by a second interview and analysis of general practitioners' records. The mortality and morbidity risks were compared for hypertensives (baseline blood pressure > or = 160/95 mmHg or antihypertensive treatment) and non-hypertensives. RESULTS: During follow-up a total of 55 men and 64 women died resulting in a 2.7-year cumulative mortality in this population of 12%. Mortality was higher in men (14%) than in women (11%). Hypertensives had no increased risk of death compared to non-hypertensives (adjusted relative risk (RR)=0. 92; 95% CI: 0.48-1.76 for men and RR=1.36; 95% CI 0.67-2.78 for women). This was confirmed in age-stratified analyses. However, among survivors hypertension was associated with a significantly higher occurrence of non-fatal cardiovascular events. After controlling for potentially confounding baseline conditions, the relative risk for any event (RR=1.44; 95% CI: 1.04-2.0) and, in particular, of acute myocardial infarction (RR=5.5; 95% CI: 1.6-18. 7) was raised among hypertensives. Higher rates for angina pectoris (RR=1.4; 95% CI: 0.9-2.4) and heart failure (RR 1.7; 95% CI: 0.9-2. 9) were of borderline significance. Positive risk associations were confined to the age group 65 to 75 years and not detected at higher ages. CONCLUSION: This study demonstrates for a Central European population older than 65 years the impact of hypertension as a risk factor for cardiovascular and cerebrovascular morbidity. To address the issue that risk of death showed no significant relationship to blood pressure, a longer follow-up period might be necessary.