Differences in cardiovascular disease risk factors between Japanese in Japan and Japanese-Americans in Hawaii: the INTERLIPID study

Despite increase in serum total cholesterol, high smoking rate, and frequency of adverse blood pressure levels in Japan, coronary heart disease (CHD) incidence and mortality apparently remain substantially lower at all ages in Japan than in the US and other Western societies. To better understand these differences, we compared CHD biomedical risk factors and dietary variables in Japanese living in Japan and 3rd and 4th generation Japanese emigrants living a primarily Western lifestyle in Hawaii, in an ancillary study of the INTERMAP. Men and women aged 40-59 years were examined by common standardized methods-four samples in Japan (574 men, 571 women) and a Japanese-American sample in Hawaii (136 men, 131 women). Average systolic (SBP) and diastolic (DBP) blood pressures were significantly higher in men in Japan than in Hawaii; there were no significant differences in women. The treatment rate of hypertension was much lower in Japan than Hawaii. Smoking prevalence was higher, markedly so for men, in Japan than Hawaii. Body mass index, serum total and low-density lipoprotein cholesterol, HbA1c, and fibrinogen were significantly lower in Japan than in Hawaii; high-density lipoprotein cholesterol was higher in Japan. Total fat, saturated fatty acid intake, and Keys dietary lipid score were lower in Japan than in Hawaii. Polyunsaturated/saturated fatty acid ratio and omega-3 fatty acid intake were higher in Japan than in Hawaii. In conclusion, levels of several, especially lipid, CHD risk factors were generally lower in Japanese in Japan than in Japanese in Hawaii. These differences were smaller for women than men between Japan and Hawaii. They may partly explain lower CHD incidence and mortality in Japan than Western industrialized countries.     

Relation of serum total cholesterol and other risk factors to risk of coronary events in middle-aged and elderly Japanese men with hypercholesterolemia: the Kyushu Lipid Intervention Study.

BACKGROUND: The role of serum total cholesterol (TC) in the development of coronary heart disease (CHD) may differ in different age groups. METHODS AND RESULTS: The relation of serum TC and other risk factors to CHD events was examined in middle-aged (<65 years) and elderly (> or =65 years) men separately in the Kyushu Lipid Intervention Study (KLIS). Subjects were 4,349 men aged 45-74 years with serum TC of 220 mg/dl or greater who had no history of myocardial infarction, coronary angioplasty, or stroke. There were 123 CHD events (ie, myocardial infarction, coronary bypass surgery, coronary angioplasty, cardiac death, and sudden death) in a 5-year follow-up period. The Cox proportional hazards model was used with baseline and follow-up serum TC, baseline high-density lipoprotein (HDL) cholesterol, hypertension, diabetes mellitus, and other factors as covariates. Serum TC concentration during the follow-up, not at baseline, was associated with an increased risk of CHD events, especially in elderly men. High concentrations of serum HDL cholesterol were associated with a modest, statistically nonsignificant decrease in the risk among middle-aged men. An increased risk of CHD events associated with diabetes mellitus was greater in middle-aged men. Hypertension and smoking were not measurably related to the risk in either middle-aged or elderly men. CONCLUSIONS: Both the serum TC concentration during follow-up and diabetes mellitus are important predictors of CHD events in Japanese men with moderately elevated serum TC.     

Trends in coronary heart disease mortality and morbidity and related factors in Finland

A marked increase in the coronary heart disease (CHD) mortality of working-age men and women occurred in Finland from the 1950s until the 1960s. Around the year 1970, CHD mortality started to decline and this decline still continues. In the age group 35-64 years the average annual decline of CHD mortality in the 1970s was 1.8% for men and 3.4% for women. Limited data available on trends in CHD morbidity show that the decline in CHD mortality is accompanied by a decline in the incidence of non-fatal myocardial infarction. CHD mortality and incidence are higher in east Finland than in west Finland and this east-west difference has so far persisted during the declining trend. The decline in CHD mortality and incidence in the 1970s has been preceded and paralleled by changes into favourable direction in dietary fat consumption and population mean levels for serum cholesterol, prevalence of smoking among adult Finnish men, control of hypertension by antihypertensive drug therapy, and management of patients with symptomatic CHD. Both the changes in life-styles and CHD risk factor levels, as well as changes in the management of patients with CHD, appear to have been contributing to the decline in CHD mortality and incidence in Finland.     

Risk factors and coronary morbimortality in a Mediterranean industrial cohort over 28 years of follow-up. The Manresa Study

OBJECTIVE: To study the incidence and mortality of coronary heart disease (CHD) and all-cause mortality in a cohort of men followed during 28 years, and their association with serum cholesterol, systolic blood pressure, glycemia, cigarette smoking and body mass index measured at baseline. RESEARCH DESIGN AND METHODS: A cohort of 1,059 men aged 30 to 59 years and free of cardiovascular diseases at baseline in 1968, was examined every five years until 1988. The last examination was performed in 1996. Information was collected in 96.4% of the participants. RESULTS: Incidence and mortality rates from CHD and from all-causes of death per 105 person-years of observation were 499.80, 235.80 and 925.33, respectively. At the end of follow-up, high levels of serum cholesterol and smoking were independently associated with the incidence and mortality from CHD adjusted for age, blood pressure, glycemia and BMI. Serum cholesterol, hyperglycemia and smoking were independently associated with all-cause mortality. CONCLUSIONS: In this industrial cohort of men, with a relatively low incidence of CHD, smoking and serum cholesterol at baseline were independently associated with the incidence of CHD over 28 years of observation.     

Prospective association between low and high total and low-density lipoprotein cholesterol and coronary heart disease in elderly men

OBJECTIVES: To examine the relationship between total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) and the incidence of coronary heart disease (CHD) in elderly men. DESIGN: Prospective. SETTING: Population based. PARTICIPANTS: A sample of 2,424, Japanese-American men aged 71 to 93 was used. MEASUREMENTS: Six years of data on incident fatal plus nonfatal CHD were examined. RESULTS: Analysis revealed a significant U-shaped relationship between age-adjusted CHD rates and both TC and LDL-C. The ranges of TC and LDL-C with the lowest risk of CHD were 200 to 219 mg/dL and 120 to 139 mg/dL, respectively. As cholesterol concentrations declined and increased beyond these ranges, the risk of CHD increased. These U-shaped relationships remained significant after adjusting for age and other risk factors. CONCLUSION: The U-shaped associations between TC and LDL-C and CHD imply a complex relationship between lipids and CHD in late life. The results indicate that elevated lipid levels should continue to be treated in healthy elderly individuals, as they are in those who are younger, although pharmacologically lowering lipids to excessively low levels in the elderly may warrant further study, as does the contribution of subclinical frailty to the relationship of lipids to CHD risk.     

Sex, age, cardiovascular risk factors, and coronary heart disease: a prospective follow-up study of 14 786 middle-aged men and women in Finland

BACKGROUND: Coronary heart disease (CHD) is markedly more common in men than in women. In both sexes, CHD risk increases with age, but the increase is sharper in women. We analyzed the extent to which major cardiovascular risk factors can explain the sex difference and the age-related increase in CHD risk. METHODS AND RESULTS: The study cohort consists of 14 786 Finnish men and women 25 to 64 years old at baseline. The following cardiovascular risk factors were determined: smoking, serum total cholesterol, HDL cholesterol, blood pressure, body mass index, and diabetes. Risk factor measurements were done in 1982 or 1987, and the cohorts were followed up until the end of 1994. The Cox proportional hazards model was used to assess the relation between risk factors and CHD risk. CHD incidence in men compared with women was approximately 3 times higher and mortality was approximately 5 times higher. Most of the risk factors were more favorable in women, but the sex difference in risk factor levels diminished with increasing age. Differences in risk factors between sexes, particularly in HDL cholesterol and smoking, explained nearly half of the difference in CHD risk between men and women. Differences in serum total cholesterol level, blood pressure, body mass index, and diabetes prevalence explained about one-third of the age-related increase in CHD risk among men and 50% to 60% among women. CONCLUSIONS: Differences in major cardiovascular risk factors explained a substantial part of the sex difference in CHD risk. An increase in risk factor levels was associated with the age-related increase in CHD incidence and mortality in both sexes but to a larger extent in women.     

Lipids and coronary heart disease in Asia

In Western countries, it has been shown that coronary heart disease (CHD) is related to high serum total cholesterol (TC) levels. In less developed continents such as Asia and Africa, serum lipid levels are low and CHD incidence is much lower as compared with Western countries. With growing urbanization and industrialization in Asia, it has been shown that there is a concomitant rise in the level of serum TC and with it a rise in CHD. In all the Asian countries, serum TC levels are also higher in the urban compared with the rural population. Singapore, the only Asian country which is 100% urbanized since 1980, showed a rise of serum TC similar to that seen in the US and UK from the 1950s to the 1980s followed thereafter by a fall. This is reflected in the trend (rise followed by a fall) of CHD morbidity and mortality as well. In spite of a declining trend in serum TC level, CHD morbidity and mortality are still high in Singapore and comparable to the Western countries. The rest of the Asian countries show a different pattern from Singapore. In general, there is still a rising trend in serum TC level and in CHD mortality in most Asian countries. However, Japan is considered an exception in having a decreasing CHD mortality in spite of an increasing trend in serum TC. This may be attributed to a better control of other CHD risk factors such as hypertension and smoking. The rising trend in serum TC level remains a cause for concern, as this will emerge as a major problem for CHD morbidity and mortality in the future.     

Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Multiple Risk Factor Intervention Trial Research Group.

To assess the combined influence of blood pressure (BP), serum cholesterol level, and cigarette smoking on death from coronary heart disease (CHD) and to describe how these associations vary with age, data on those factors and on mortality for 316,099 men screened for the Multiple Risk Factor Intervention Trial (MRFIT) were examined. Vital status of participants has been determined after an average follow-up of 12 years; 6327 deaths from CHD have been identified. Strong graded relationships between serum cholesterol levels above 4.65 mmol/L (180 mg/dL), systolic BP above 110 mm Hg, and diastolic BP above 70 mm Hg and mortality due to CHD were evident. Smokers with serum cholesterol and systolic BP levels in the highest quintiles had CHD death rates that were approximately 20 times greater than nonsmoking men with systolic BP and cholesterol levels in the lowest quintile. Systolic and diastolic BP, serum cholesterol level, and cigarettes per day were significant predictors of death due to CHD in all age groups. Systolic BP was a stronger predictor than diastolic BP. These results, together with the findings of clinical trials, offer strong support for intensified preventive efforts in all age groups.     

High density lipoprotein cholesterol and myocardial infarction or sudden coronary death: a prospective case-control study in middle-aged men of the Oslo study.

The high density lipoprotein (HDL) cholesterol concentrations of frozen specimen obtained in 1972-73 are reported from 93 men aged 40-49 years who later developed coronary heart disease (CHD), and for 186 controls. Mean HDL cholesterol of CHD-patients was 7.9% lower than that of controls matched for smoking habits and serum concentrations of triglycerides and total cholesterol (p 0.05 for 82 men who had myocardial infarction, n.s. difference for 11 with sudden coronary death), and 10.2% lower (p 0.05) than that of controls who were not matched for the parameters mentioned. The present prospective study confirms that HDL cholesterol is inversely associated with the risk of developing CHD in middle-aged men.     

Sex differential in the relationship of electrocardiographic ST-T abnormalities to risk of coronary death: 11.5 year follow-up findings of the Chicago Heart Association Detection Project in Industry

The independent contributions of ST segment depression and/or T wave abnormality (ST-T abnormalities) on the baseline resting electrocardiogram to risk of 11.5 year coronary heart disease (CHD) mortality were explored among 9203 white men and 7818 white women who were 40 to 64 years old and without definite CHD at entry in the Chicago Heart Association Detection Project in Industry. At baseline, prevalence rates of ST-T abnormalities were age related for both sexes, and at every age the rate was higher in women than men (age-adjusted prevalence rates 12.3% and 8.1%, respectively). Univariate analysis showed that ST-T abnormalities were associated with significantly increased risk of death from CHD for both men and women. However, men with ST-T abnormalities had much greater age-adjusted and multiple risk factor-adjusted absolute excess risk and relative risk than women with such electrocardiographic abnormalities. When baseline age, diastolic pressure, serum cholesterol, cigarettes/day, history of diabetes, and baseline use of antihypertensive medication were included in the multivariate analysis, ST-T abnormalities remained significantly related to death from CHD in men but not women. The interaction term between sex and ST-T abnormalities was at a borderline level of statistical significance by Cox regression analysis. In conclusion, ST-T abnormalities indicate an increased risk of subsequent death from CHD independent of major coronary risk factors for middle-aged U.S. men, but this is not clearly so for women.     

Lifestyle and cardiovascular disease in Japan

The aim was to give on overview of the profile of cardiovascular disease, vascular pathology and the relationships between lifestyle and cardiovascular disease in Japanese. Compared with the United States and Europe, the higher mortality from stroke and lower mortality from coronary heart disease constitute a unique cardiovascular profile for Japan. A selective review of population-based pathology, trend and prospective cohort studies was performed to clarify the characteristics of cardiovascular disease and vascular pathology, trends in the incidence and mortality of cardiovascular disease, and the relationships between lifestyle and cardiovascular disease among Japanese adults. Since the 1970s, mortality from coronary heart disease as well as stroke has declined substantially in Japan, probably due to a major decline in blood pressure levels and for men a more recent decline in smoking, in spite of an increase in body mass index and total cholesterol levels. However, the decline in mortality was smaller and plateaued in middle-aged men aged 30-49 in the metropolitan cities of Tokyo and Osaka. The incidence of coronary heart disease has increased among middle-aged men residing in the suburbs of Osaka. As for the associations between lifestyle and cardiovascular disease, higher sodium, lower calcium and lower animal protein content in the diet and for men higher alcohol consumption may account for the higher prevalence of hypertension and higher risk of stroke for Japanese than for western populations. On the other hand, lower saturated fat (meat) and higher n3 polyunsaturated fat (fish) in the Japanese diet may contribute to the lower prevalence of hypercholesterolemia and lower risk of coronary heart disease among Japanese. Japan is unique among developed countries in that coronary heart disease mortality has been low and has continued to decline, while stroke mortality has declined substantially. However, a recent trend for coronary heart disease incidence to increase among urban men is a cause for concern as a potential source of future problems for public health and clinical practice in Japan.     

The marked decline in coronary heart disease mortality rates in the United States, 1968-1981; summary of findings and possible explanations

During the years 1940-1967, age-adjusted mortality rates from coronary heart disease (CHD) rose in the USA by 14.1% for all persons aged 35-74. This upward trend was recorded for white men, black men, and black women, but not for white women. From 1968 to 1981 (year of latest record), the trend in the preceding period was reversed, i.e., CHD death rates decreased steadily, at a rate averaging about 3% per year. This downward trend has involved all age-sex-color groups in the adult population and all regions of the country. It has encompassed both main categories of CHD, i.e., acute myocardial infarction (AMI) and chronic ischemic heart disease (CIHD), the former more prominently than the latter, especially among adults aged 35-64. The US decline in CHD mortality rates is greater-absolutely and relatively-than that of any other country. US death rates from stroke have also fallen markedly over these years, so that death rates from the major cardiovascular diseases (CVD) and all causes also fell substantially, with savings of hundreds of thousands of people from premature death since 1968. Responding to vigorous development in the USA over the last 25 years of public policy and strategy for the prevention and control of the coronary epidemic, tens of millions of Americans have made changes in eating habits resulting in lower population mean intake of total fat, saturated fat, cholesterol; increased intake of polyunsaturated fats; decreased mean levels of serum cholesterol and rates of hypercholesterolemia. Prevalence rates of cigarette smoking among adults have also decreased markedly. Tens of millions have taken up leisure time exercise. All these changes have occurred more among the more educated-affluent than among the less educated-affluent. Over the last decade the proportion of persons with hypertension whose hypertension was detected, treated, and controlled has risen from 10 to 15% to embrace a majority of hypertensives. It is a reasonable inference that these mass changes in life-styles and life-style-related major CHD risk factors have contributed importantly to the large sustained declines in CHD, CVD, and all causes death rates in the USA. Concordant with this inference are data sets indicating greater declines in CHD mortality among the more educated-affluent strata than among the general population (matched for age-sex-color), in keeping with the greater changes in life-styles among the more educated-affluent, e.g., as exemplified by findings for physicians.(ABSTRACT TRUNCATED AT 400 WORDS)     

Forty-year follow-up of coronary heart disease mortality and its predictors: the Corfu cohort of the seven countries study

The authors examined the effect of several risk factors in relation to coronary heart disease (CHD) mortality in the Corfu cohort of the Seven Countries Study. The population studied in this analysis consisted of 529 rural men (age 40-59 years) enrolled in 1961. Multivariate analysis was performed with CHD death as the end point; age, blood pressure, heart rate, serum total cholesterol, smoking, physical activity, body mass index, skinfold thickness, vital capacity, and forced expiratory volume were the predictors. The 40-year CHD survival rate was 63% (108 deaths). Age (hazard ratio [HR]=1.093; p<0.001), smoking (HR=1.79; p<0.05), body mass index (HR=1.05; p<0.1), and serum total cholesterol (HR=1.004; p<0.2) were independently associated with 40-year CHD mortality. Conclusively, in men from the Corfu cohort, age, lifestyle habits (expressed as smoking and body mass index), and serum cholesterol levels were consistently associated with 40-year CHD mortality. In addition, the current status of men in the Corfu cohort is marked by long-term adoption of a Mediterranean type of diet, physical activity, and optimism.     

Coffee consumption and the risk of coronary heart disease and death

OBJECTIVES: To study prospectively the relation of coffee drinking with fatal and nonfatal coronary heart disease (CHD) and all-cause mortality and to perform a cross-sectional analysis at baseline on the association between coffee drinking and CHD risk factors, diagnosed diseases, self-reported symptoms, and use of medicines. METHODS: The study cohort consisted of 20 179 randomly selected eastern Finnish men and women aged 30 to 59 years who participated in a cross-sectional risk factor survey in 1972, 1977, or 1982. Habitual coffee drinking, health behavior, major known CHD risk factors, and medical history were assessed at the baseline examination. Each subject was followed up for 10 years after the survey using the national hospital discharge and death registers. Multivariate analyses were performed by using the Cox proportional hazards model. RESULTS: In men, the risk of nonfatal myocardial infarction was not associated with coffee drinking. The age-adjusted association of coffee drinking was J shaped with CHD mortality and U shaped with all-cause mortality. The highest CHD mortality was found among those who did not drink coffee at all (multivariate adjusted). Also, in women, all-cause mortality decreased by increasing coffee drinking. The prevalence of smoking and the mean level of serum cholesterol increased with increasing coffee drinking. Non-coffee drinkers more often reported a history of various diseases and symptoms, and they also more frequently used several drugs compared with coffee drinkers. CONCLUSIONS: Coffee drinking does not increase the risk of CHD or death. In men, slightly increased mortality from CHD and all causes in heavy coffee drinkers is largely explained by the effects of smoking and a high serum cholesterol level. Arch Intern Med. 2000;160:3393-3400.     

Association of lipids and lipoprotein level with total mortality and mortality caused by cardiovascular and cancer diseases (Poland and United States collaborative study on cardiovascular epidemiology).

This study evaluates the relation between total serum cholesterol, triglycerides, and high-density lipoprotein (HDL) cholesterol, and subsequent total, cardiovascular, and cancer mortality. These data are from 4,946 US and 5,198 Polish men and women aged 35 to 64 years at baseline with mortality follow-up over 13 years. Total cholesterol showed a U-shaped or J-shaped relation to age-adjusted total and cancer mortality across all samples, with significance only in Polish women. The multivariable adjusted relative risk for total and cancer mortality was higher in the lowest cholesterol category only in Poland and significant only for cancer. Cardiovascular mortality was positively related to cholesterol, but only in Polish men and US women was mortality significantly higher in the highest versus the lowest cholesterol category. The multivariable adjusted relative risk of cardiovascular death was greater in the highest versus the lowest cholesterol category, but this trend was significant only in the US. HDL cholesterol was inversely related to total (significant only in US men) and cardiovascular mortality (significant only in US and Polish men). A similar, but not significant, association of HDL cholesterol was found with cancer mortality. The multivariable adjusted relative risk of total mortality was inversely related to HDL cholesterol significant in both the US and Poland. The relative risk of cardiovascular mortality was significantly lower at higher HDL cholesterol levels in all samples. The relative risk of cancer mortality was highest and significant at the lowest HDL cholesterol level in the US and Poland. Elevated triglycerides were associated with increased risk of total and cardiovascular mortality, but this trend was significant only in the US. Cancer mortality was not significantly related to triglycerides. The present study indicates that in geographically and culturally diverse populations, the relation of lipids with cardiovascular mortality is similar. The relation with total and cancer mortality varies by country, gender, and lipids. This suggests that relations of total and cancer mortality with lipids or lipoproteins are weaker than associations with cardiovascular mortality.     

Early and late coronary deaths in the US Railroad study predicted by major coronary risk factors.

BACKGROUND: The purpose of this study was to explore the duration of the association of major coronary risk factors measured on a single occasion with coronary heart disease (CHD) deaths during 40 years in a population sample of middle-aged men. DESIGN: Measurement of age, systolic blood pressure, serum total cholesterol, and cigarette smoking was made on a single occasion in 2376 cardiovascular disease free men, aged 40-59, belonging to the US Railroad cohort of the Seven Countries Study enrolled in the late 1950s. During 40 years of follow up 627 men died from typical CHD (sudden death coronary death or definite myocardial infarction). METHODS: Eight partitioned proportional hazards models were solved, one for each independent 5-year block of follow up, to predict the risk of CHD death. Eight 5-year partitioned hazard scores, derived from the coefficients, were cumulated for each risk factor. RESULTS: The resulting curves showed a regularly increasing time trend in risk for coronary deaths as a function of serum cholesterol, systolic blood pressure and cigarette smoking, for the first 30-35 years of follow up followed by a loss of predictive power thereafter. The curves fit straight lines, with large squared correlation coefficients ranging from 0.96 to 0.99. There was a relatively constant strength in the association of risk factors levels with events, which are predicted irrespective of the distance from risk factor measurements. CONCLUSIONS: Measurement of major coronary risk factors taken on a single occasion in middle-aged men maintained a regular and almost monotonic relationship with the subsequent occurrence of CHD deaths for at least 30-35 years of follow up.     

Impaired protection against diabetes and coronary heart disease by high-density lipoproteins in Turks

The issue of whether or not incident type 2 diabetes mellitus and coronary heart disease (CHD) can be predicted by high-density lipoprotein (HDL) cholesterol in both sexes needs investigation. A representative sample of 3035 middle-aged Turkish adults free of CHD at baseline was studied with this purpose prospectively over a mean of 7.8 years. High-density lipoprotein cholesterol levels were found to be correlated in women positively with plasma fibrinogen and weakly with waist girth and C-reactive protein, and to be not correlated with fasting insulin. High-density lipoprotein cholesterol protected men against future CHD risk (for a 12-mg/dL increment: relative risk = 0.80 [95% confidence interval, 0.69-0.95]) after multivariable adjustment in logistic regression analyses for age, smoking status, physical activity grade, hypertension, abdominal obesity, diabetes, and lipid-lowering drugs. However, men were not protected against risk of diabetes. In women, HDL cholesterol was not associated with risk for CHD, whereas intermediate (40-60 mg/dL) compared with lower HDL cholesterol levels proved protective against risk of diabetes (relative risk = 0.57 [95% confidence interval, 0.36-0.90]) after adjustments that included apolipoprotein A-I tertiles. Yet higher serum concentrations failed to yield protection against diabetes. It was concluded that HDL particles confer partially lacking protection against cardiometabolic risk among Turks, and this impairment is modulated by sex. This highly important observation may result from a setting of prevailing chronic subclinical inflammation.     

Trends for coronary heart disease and its risk factors in Japan: epidemiologic and pathologic studies

Epidemiologic and pathologic studies were conducted between 1965 and 1986 to investigate trends for the incidence of coronary heart disease (CHD) and its risk factors in urban and rural populations and to relate the risk factor changes to trends for CHD incidence and pathologic findings. The epidemiologic study included men aged 40-59 years who urban residents of Osaka, clerical and manual workers in Osaka, and rural residents of Akita prefecture. The pathologic study subjects were autopsied men aged 30 and over, admitted to a local hospital in Akita, whose autopsy rate was 88%. From a cohort of 8,835 urban employees between 1975 and 1987, risk factors for myocardial infarction were identified: blood pressure, total serum cholesterol, blood glucose and cigarette smoking all which were compatible with findings in the US and European countries. For rural residents, serum cholesterol was less likely to be associated with the CHD incidence. Little contribution of serum cholesterol to development of coronary heart disease in rural men was supported by the pathologic study showing no significant association between serum cholesterol and the coronary atherosclerosis. Myocardial infarction from urban patients was characterized as massive necrosis in the myocardium with coronary artery stenosis and minimum atherosclerosis of basal cerebral arteries while that from rural men was small scattered necrosis in myocardium with atherosclerosis in both coronary and basal cerebral arteries. There was an increasing trend in the incidence of myocardial infarction in urban men but no change in rural men. The difference in the incidence trend can be attributed in part to differences in pathologic etiology and in blood pressure and serum cholesterol levels. Systematic surveillance is underway in both urban and rural population to clarify future trends for coronary heart disease and its risk factors.     

Update on Hyperlipidemia in the Elderly: Is This a Risk Factor for Heart Disease?

Results concerning the utility of lipid screening in the elderly are conflicting. Many studies have shown no association between total cholesterol measurements in the elderly and the development of coronary heart disease (CHD). Several recent investigations, with a few exceptions, have demonstrated that high-density lipoprotein-cholesterol (HDL-C) levels and the total/HDL-C ratio are, however, effective markers for CHD in older populations. Although the relative risk associated with lipid measurements tends to decline in older persons, the attributable risk for CHD associated with higher cholesterol and lower HDL-C tends to be greater in older persons because of a greater number of events in this population. Clinical trials with modern lipid-lowering agents have demonstrated efficacy and safety in middle-aged subjects with the newer medications, and it is time to consider a lipid altering clinical trial specifically targeted to persons over the age of 65 years to determine whether morbidity and mortality can be reduced.     

40-Year CHD Mortality Trends and the Role of Risk Factors in Mortality Decline: The North Karelia Project Experience

In the 1960s and early 1970s, coronary heart disease (CHD) mortality in Finland was the highest in the world, and within Finland, mortality was particularly high in the eastern part of the country. The North Karelia Project, the first large community-based cardiovascular diseases prevention program was established in 1972 to reduce the extremely high CHD mortality through behavioral change and reduction of the main cardiovascular disease risk factors among the whole population of North Karelia, the easternmost province of Finland. During the 40-year period from 1972 to 2012, smoking prevalence, serum total cholesterol, and systolic blood pressure declined markedly, except a small increase in serum cholesterol levels between 2007 and 2012. From the early 1970s to 2012, CHD mortality decreased by 82% (from 643 to 118 per 100,000) among working-age (35 to 64 years) men. Among working-age women, the decline was 84% (from 114 to 17 per 100,000). During the first 10 years, changes in these 3 target risk factors explained nearly all of the observed mortality reduction. Since the mid-1980s, the observed reduction in mortality has been larger than the predicted reduction. In the early 1970s, premature CHD mortality (35 to 74 years) was about 37% higher among Eastern Finnish men and 23% higher among Eastern Finnish women, compared with men and women in Southwestern Finland. During the last 40 years, premature CHD mortality declined markedly in both areas, but the decline was larger in Eastern Finland and the mortality gap between the two areas nearly disappeared.