Prevalence of cardiovascular disease risk factors in blacks and whites: the Minnesota Heart Survey.

Two cross-sectional surveys were conducted in 1985 and 1986 to measure the prevalence of coronary heart disease (CHD) risk factors in Blacks and Whites. A home interview was followed by a survey center visit. Participation rates were 78 per cent and 90 per cent for the home interview and 65 per cent and 68 per cent for the survey center visit. Adjusted for age and education, systolic and diastolic blood pressure was 3 to 4 mmHg higher in Blacks. Hypertension was more prevalent in Blacks than Whites (44 per cent vs 28 per cent); serum total cholesterol was approximately 0.4 mmol/l lower in Black than White men and 0.08 mmol/l lower in Black than White women. Among men, more Blacks than Whites were current cigarette smokers (44 per cent vs 30 per cent); however, White smokers smoked more cigarettes per day (26 vs 17). Similar differences were noted for women, although the prevalence and quantity of cigarette consumption was less than men. The excess prevalence of these CHD risk factors in Blacks, especially among women, may explain their elevated CHD and stroke mortality rates in the Twin Cities.     

Management of ischaemic heart disease in primary care: towards better practice. STaRNet. South Thames Region Network.

BACKGROUND: Ischaemic heart disease is the commonest cause of mortality in the United Kingdom. The objective of this study was to assess the management of patients with ischaemic heart disease in primary care, focusing particularly on the management of hypercholesterolaemia. METHODS: A cross-sectional survey was carried out of the clinical records of patients aged 25-74 years with confirmed ischaemic heart disease in six general practices (total list size 56 600). RESULTS: Recording of risk factors varied from 97 per cent for blood pressure to 73 per cent for cholesterol measurement. Seventy-two per cent of the patients had adequate blood pressure control, based on their last recorded blood pressure. Sixty-one per cent (267) were known to be taking aspirin daily and 29 per cent (125) had undergone revascularization treatment. Sixty-eight per cent (296) of the patients had pre-treatment cholesterol levels of 5.5 mmol/l or greater and 34 per cent (147) were currently taking lipid lowering drugs. Statins were the most commonly used cholesterol lowering agents and were being taken by 30 per cent (131) of the patients. Patients who had undergone revascularization treatment had levels of recording of risk factors similar to other patients with ischaemic heart disease but were more likely to be taking daily aspirin (71 per cent versus 57 per cent, relative risk 1.24, 95 per cent confidence intervals (CI) 1.07-1.44). The mean pre-treatment cholesterol was 6.49mmol/l and the mean post-treatment cholesterol 5.80 mmol/l (difference 0.69 mmol/l, 95 per cent CI 0.55-0.84 mmol/l). CONCLUSIONS: Systematic searches of computerized and paper medical records can identify subgroups of patients who will benefit from continuing follow-up in primary care. The results of this study suggest that ischaemic heart disease remains an area where there is scope to improve the management of patients in primary care. Considerable effort will be required from the members of the primary health care team to achieve this objective, particularly in the areas of computerized data collection and in the identification and recall of patients.     

The importance of HDL-cholesterol level determination in the classification of persons at increased risk of coronary heart disease]

The evidence is growing that not only total cholesterol, but also HDL cholesterol is an important predictor of coronary heart disease. In the Framingham Study, the total cholesterol/HDL cholesterol ratio gave the best prediction for the coronary heart disease risk. With data of the Netherlands Monitoring Risk Factor Project it was investigated to what extent persons with a high ratio (greater than or equal to 7) were identified when the criteria of the Netherlands Cholesterol Consensus were applied. Between 1987 and 1989 total and HDL cholesterol were determined in about 22,000 men and women aged 20-59. Twenty per cent of the men had hypercholesterolaemia (total cholesterol greater than or equal to 6.5 mmol/l). Of the hypercholesterolaemic men, 60 per cent did not have a high total/HDL cholesterol ratio. Eighteen per cent of the women were hypercholesterolaemic. Of all hypercholesterolaemic women, 80 per cent did not have a high total/HDL cholesterol ratio. Therefore, it is important that after a first screening on total cholesterol, HDL cholesterol is measured at the second cholesterol determination. Subsequently, a decision about treatment should be made, based on the total/HDL cholesterol ratio and the presence of other risk factors (hypertension, smoking, obesity, diabetes and a family history of cardiovascular disease.     

Coronary arteriography and coronary bypass survey among whites and other racial groups relative to hospital-based incidence rates for coronary artery disease: findings from NHDS.

To assess racial differences in health care utilization for coronary artery disease (CAD) the data of the National Hospital Discharge Survey (NHDS) from 1979-84 were examined. Discharge rates for acute myocardial infarction (AMI) were utilized as a measure of hospital-based incidence and relative need for the designated cardiac procedures. Although 35-74 year old Black men had discharge rates of AMI that were 77 per cent of those observed for White men, they underwent coronary arteriography half as often and were only a third as likely to have coronary artery bypass graft (CABG) surgery. Black women in this age range were hospitalized at a slightly higher rate than White women for AMI, yet experienced a 19 per cent lower rate of coronary arteriography and a 52 per cent lower rate of CABG surgery. These data suggest a racial bias in the pattern of care delivered for CAD in US hospitals at the present time.     

Managing heart failure in primary care: first steps in implementing the National Service Framework

BACKGROUND: Heart failure is common, causes considerable morbidity, and imposes a major financial burden on both society and the National Health Service. The National Service Framework (NSF) for Coronary Heart Disease (CHD) set national standards for the management of people with heart failure in England. We examined how patients with heart failure were investigated and treated compared with NSF standards, and explored the current constraints in improving the care of these patients. METHODS: This study was carried out in two general practices (total list size 19,600) in south London. Using a computer search strategy, patients with possible heart failure were identified and clinical data extracted from their medical records. Workshops on heart failure were held at a national conference on disease management in primary care, and key stakeholders were interviewed to identify constraints in improving management. RESULTS: Ninety patients with heart failure were identified through the computerized search. Seventy-eight patients (87 per cent) had a Read code for heart failure on their electronic medical record. Forty-eight (53 per cent) patients were men and 10 (12 per cent) were aged less than 65 years. Forty-nine per cent of patients had undergone an electrocardiogram and 42 per cent an echocardiogram. Angiotensin-converting enzyme (ACE) inhibitors were prescribed to 54 per cent of patients. In the workshops and stakeholder interviews, healthcare professionals and managers reported difficulties in implementing the NSF. They expressed concerns regarding the difficulties in confirming a diagnosis of heart failure, including access to echocardiograms, prescribing ACE inhibitors among older patients, and the additional workload and resources needed to ensure they met the NSF standards for heart failure. CONCLUSION: The accurate identification of heart failure patients and recording of clinical information as part of disease registers needs to improve if primary care teams are to meet the NSF standards. There is also scope to improve the investigation and treatment of heart failure patients in primary care. Achieving these objectives will require additional resources.     

Epidemiologic aspects of coronary heart disease in Malm?, Sweden, 1935-1988

Mortality from coronary heart disease has declined for more than 20 years in several industrialized countries. Partly because of a lack of morbidity data, the reasons for the decline are not satisfactorily established. This community-wide survey of coronary heart disease morbidity and mortality in Malm?, Sweden, showed declining mortality rates beginning in the mid-1970s. Between the 3-year intervals 1975-1977 and 1984-1986, coronary heart disease mortality declined by 17% (2,610/100,000 inhabitants in 1984-1986) in men aged greater than or equal to 70 years and by 8% (938/100,000 inhabitants in 1984-1986) in men aged 60-69 years, while coronary heart disease mortality in men aged 50-59 years increased by 7% (355/100,000 inhabitants in 1984-1986). In women aged greater than or equal to 70 years, coronary heart disease mortality decreased by 12% between 1975-1977 and 1984-1986 (1,609/100,000 inhabitants in 1984-1986), while the decrease in women aged 60-69 years was 5% (242/100,000 inhabitants in 1984-1986). The decline in mortality was associated with a decline in both incidence rates and in-hospital case fatality rates for myocardial infarction. The authors suggest that the declining coronary heart disease mortality in Malm? was due partly to prevention of coronary heart disease but that improved medical care for acute and chronic coronary heart disease may also have contributed.     

A self–administered questionnaire for detection of unrecognised coronary heart disease

Abstract: On an individual and a population basis, an increased incidence of coronary heart disease is associated with classical cardiovascular risk factors, but many cases occur in people not identified as at high risk. Conversely, many people at high statistical risk do not develop coronary disease. We used a questionnaire to identify unrecognised coronary heart disease in people attending large–scale health survey centres. Participants were required to report the presence and characteristics of any chest pain. Those returning responses consistent with myocardial ischaemia were offered treadmill exercise ECG tests. Over 18 months, 4070 questionnaires were returned. Of 475 respondents offered testing, 229 (198 male, 131 female) accepted. Thirty–two subjects (15 male, 17 female: a detection rate of 13.9 per cent of those assessed as likely on questionnaire, or 0.8 per cent of all respondents) had results consistent with significant coronary heart disease. Follow–up was available in 30 cases. There was no difference in classical risk–factor distribution (including multivariate risk percentiles: 42.4 (male) and 46.7 (female)) between those newly diagnosed with coronary heart disease and their community counterparts. More women than men were identified as suffering from unrecognised coronary heart disease, with a preponderance of younger women. Cost per case identified was A$1220. Screening by self–administered questionnaire is a useful and relatively cost–effective means of identifying unrecognised coronary heart disease. ( Aust N Z J Public Health 1997; 21: 545–7)     

Serum triglycerides and risk of coronary heart disease among Japanese men and women

To examine the relation of triglycerides with coronary heart disease among populations with low mean total cholesterol, the authors conducted a 15.5-year prospective study ending in 1997 of 11,068 Japanese aged 40-69 years (4,452 men and 6,616 women with mean total cholesterol = 4.73 mmol/liter and 5.03 mmol/liter, respectively), initially free of coronary heart disease or stroke. There were 236 coronary heart disease events comprising 133 myocardial infarctions, 68 angina pectoris events, and 44 sudden cardiac deaths. The coronary heart disease incidence was greater in a dose-response manner across increasing quartiles of nonfasting triglycerides for both sexes. The multivariate relative risk of coronary heart disease adjusting for coronary risk factors and time since last meal associated with a 1-mmol/liter increase in triglycerides was 1.29 (95% confidence interval (CI): 1.09, 1.53; p = 0.004) for men and 1.42 (95% CI: 1.15, 1.75; p = 0.001) for women. The trend was similar for myocardial infarction, angina pectoris, and sudden cardiac death. The relation of triglycerides with coronary heart disease was not influenced materially by total cholesterol levels or, in a subsample analysis (51% of total sample), by high density lipoprotein cholesterol levels. Nonfasting serum triglycerides predict the incidence of coronary heart disease among Japanese men and women who possess low mean values of total cholesterol. Further adjustment for high density lipoprotein cholesterol suggests an independent role of triglycerides on the coronary heart disease risk.     

Plasma fibrinogen and coronary heart disease in urban Japanese

There is little information on the relation of plasma fibrinogen concentration to the risk of coronary heart disease in Asians, including Japanese, whose plasma fibrinogen concentration has been reported to be low by Western standards. The authors conducted a prospective study with 4.8 years of follow-up of 11,977 men and women aged 21-89 years (mean value of fibrinogen = 267 mg/dl) living or working in Osaka, Japan, in 1990-1996 to examine the relation of plasma fibrinogen with the incidence of coronary heart disease (myocardial infarction and angina pectoris). Mean fibrinogen concentration was 293.6 mg/dl for men who developed coronary heart disease (n = 35) compared with 261.6 mg/dl for men free of coronary heart disease (n = 8,094; difference, p < 0.01), and 355.2 mg/dl for women who developed coronary heart disease (n = 6) compared with 276.8 mg/dl for women free of coronary heart disease (n = 3,842; difference, p < 0.01). With a Cox proportional hazards model to adjust for cardiovascular risk factors, the relative risk for the highest fibrinogen quartile (> or =295 mg/dl) compared with the lowest (<228 mg/dl) was 4.8 (95% confidence interval: 1.4, 16.8, p = 0.01) for coronary heart disease, and 3.8 (95% confidence interval: 1.1, 13.4, p = 0.04) for myocardial infarction. Plasma fibrinogen is useful to predict the risk of coronary heart disease among urban Japanese, whose mean plasma fibrinogen is relatively low.     

The Good Heart,Good Life survey: self-reported cardiovascular disease risk factors,health knowledge and attitudes among Greek-Australians in Sydney

Abstract: This survey aimed to assess the prevalence and knowledge of coronary risk factors and self-perceived coronary heart disease risk among Greek-Australians in the Marrickville area of inner Sydney. A random sample of 834 household addresses was selected from the 2 403 households having Greek-Australian surnames on the electoral roll. In each household, one individual aged 18 years or over was selected using a Kish grid, and a questionnaire was administered by a bilingual interviewer. Questions concerned knowledge of and self-reported risk factors for coronary heart disease, and ratings of perceived stress, social support and networks. There was a response rate of 81 per cent of actual Greek-Australian households, a total of 541 interviews (61 per cent women). Most of the sample (86 per cent) were born in Greece and 77 per cent of interviews were administered in Greek. The age-adjusted male prevalences of self-reported smoking, high blood pressure, high blood cholesterol and body mass index over 26 kg/m² were 44 per cent, 5 per cent, 14 per cent and 58 per cent, respectively. The age-adjusted female prevalences of self-reported smoking, high blood pressure, high blood cholesterol and body mass index over 26 kg/m² were 19 per cent, 8 per cent, 15 per cent and 40 per cent, respectively. Compared to the National Heart Foundation risk-factor prevalence survey, the prevalence of self-reported high blood pressure was lower, but obesity and, among males, smoking, were higher. Low levels of education and poor English-language skills among older Greek-Australians may be contributing to the problem. There is a need for linguistically and culturally appropriate health promotion programs for communities of non-English-speaking background.     

A prospective study of age at menarche, parity, age at first birth, and coronary heart disease in women

Reproductive events in women are associated with alterations in blood lipids and blood pressure and may therefore influence determinants of coronary heart disease. To investigate the risk of coronary heart disease in relation to age at menarche, parity, and age at first birth, the authors evaluated prospectively the experience of 119,963 US women aged 30-55 years who were free from coronary heart disease in 1976 and were followed through 1982. During 700,809 person-years of observation, 308 incident cases of nonfatal myocardial infarction or fatal coronary heart disease occurred. Younger age at menarche was weakly associated with coronary heart disease (age-adjusted rate ratio of 1.3 for menarche before age 11 years compared with menarche at age 13 years; chi, Mantel extension test for trend = -1.1, p = 0.2). Nulliparous women experienced only a slightly higher rate of coronary heart disease than parous women (rate ratio = 1.2, 95 per cent confidence interval 0.8-1.8). Among parous women, there was no alteration in risk with increasing number of births. Likewise, there was no significant association between age at first birth and coronary heart disease (chi, Mantel extension test for trend = -0.4, p = 0.4). Established risk factors for coronary heart disease nevertheless showed expected relations. These findings show no important association between reproductive experiences and risk of coronary heart disease.     

Pulmonary function as a predictor of coronary heart disease

The role of pulmonary function as an independent predictor of coronary heart disease was examined in 1965-1983 in a cohort of Japanese-American men. As part of the Honolulu Heart Program, the authors measured pulmonary function in 5,924 men aged 45-68 years who were free of coronary heart disease at baseline examination and followed them for 15-18 years for the development of nonfatal myocardial infarction and fatal coronary heart disease. Per cent predicted forced expiratory volume in one second (%PFEV1) was significantly inversely related to coronary heart disease incidence in the total cohort after adjusting for age (p less than 0.0001) and then for all known coronary heart disease risk factors (p = 0.0004). However, when examined by smoking status, %PFEV1 was a predictor of coronary heart disease only among past and current smokers, and not for men who had never smoked cigarettes (p = 0.36). The association between pulmonary function and coronary heart disease can be explained by cigarette smoking, which leads to both lung impairment and coronary heart disease incidence.     

Impact of Baby Boomers on hospitalizations for coronary heart disease and stroke in the United States

OBJECTIVE: Comparison of hospitalizations for coronary heart disease and stroke in older Baby Boomers, aged 45-54 years (the 1946-1955 birth cohort) in 2000 with that of the 1936-1945 birth cohort in 1990 and the 1926-1935 birth cohort in 1980. METHOD AND DATA SOURCE: Analysis of the annual National Hospital Discharge Survey that collects data on discharges from non-federal short-stay hospitals. RESULTS: Among hospitalizations for coronary heart disease, 294,000 (15.4%) in 1980, 289,000 (14.7%) in 1990, and 329,000 (15.2%) in 2000 occurred among adults aged 45-54 years. However, the age-specific hospitalization rate (per 100,000) for coronary heart disease was lower in 2000 than in 1990 or 1980 (p<0.05). Among hospitalizations for stroke, 37,000 (6.0%) in 1980, 42,000 (6.5%) in 1990, and 64,000 (8.5%) in 2000 were observed in this age group. The age-specific hospitalization rate (per 100,000) for stroke in 2000 compared to that in 1990 or 1980 was higher among women (p<0.05) but lower among men (p<0.05). The proportion of transfers to another care facility after discharge in 2000, 1990, and 1980 increased for coronary heart disease and stroke in successive decades of middle-aged adults. CONCLUSION: Baby Boomers made a greater impact on absolute numbers of coronary heart disease and stroke hospitalizations in 2000 relative to that of 45-54-year-olds in 1990 and 1980.     

Women, work and coronary heart disease: prospective findings from the Framingham heart study.

This study examined the relationship of employment status and employment-related behaviors to the incidence of coronary heart disease (CHD) in women. Between 1965 and 1967, a psychosocial questionnaire was administered to 350 housewives, 387 working women (women who had been employed outside the home over one-half their adult years), and 580 men participating in the Framingham Heart Study. The respondents were 45 to 64 years of age and were followed for the development of CHD over the ensuing eight years. Regardless of employment status, women reported significantly more symptoms of emotional distress than men. Working women and men were more likely to report Type A behavior, ambitiousness, and marital disagreements than were housewives; working women experienced more job mobility than men, and more daily stress and marital dissatisfaction than housewives or men. Working women did not have significantly higher incidence rates of CHD than housewives (7.8 vs 5.4 per cent, respectively). However, CHD rates were almost twice as great among women holding clerical jobs (10.6 per cent) as compared to housewives. The most significant predictors of CHD among clerical workers were: suppressed hostility, having a nonsupportive boss, and decreased job mobility. CHD rates were higher among working women who had ever married, especially among those who had raised three or more children. Among working women, clerical workers who had children and were married to blue collar workers were a highest risk of developing CHD (21.3 per cent).     

High mortality from renal disease and infection in Aboriginal central Australians with diabetes

Abstract: Few studies have examined the consequences of the high prevalence of diabetes in Aboriginal communities. We aimed to determine the rates and causes of mortality in all Aboriginal central Australians with diagnosed diabetes, identified by a previous study (n = 374). Cohort members were followed from 1 January 1984, or the date of diagnosis (to 31 December 1986), to 31 December 1991 or death. Death certificates, medical notes and autopsy reports were examined for cause of death. There were 130 deaths in 2280.7 person–years of follow-up. Standardised mortality ratios for Aboriginal people with diabetes, compared to the Northern Territory Aboriginal population, were 209 (95 per cent confidence interval (CI) 158 to 273) for men and 169 (CI 129 to 218) for women. The difference in ratios for men and women was not statistically significant when adjusted for age (P = 0.2). The eight-year survival rates for men and women diagnosed between 1984 and 1986 were 55.8 per cent (CI 32.6 to 73.7) for men and 80.3 per cent (CI 64.8 to 89.5) for women. Renal disease was the direct cause of death in 22.3 per cent Infection accounted for 20.8 per cent of deaths and ischaemic heart disease for 13.8 per cent Forty-four per cent of death certificates made no mention of diabetes. Diabetes confers an additional risk of death on a population whose mortality is already markedly worse than that of other Australians. Unlike Western diabetic populations, infections and renal disease were more common causes of death than macrovascular disease. Diabetes amplifies the effect of the community prevalence of infection and renal disease.     

Cardiovascular risk factors and prevalence of coronary heart disease in type 2 (non-insulin-dependent) diabetes

The relationship between cardiovascular risk factors and the prevalence of coronary heart disease was examined in 152 Type 2 diabetic patients (65 men, 87 women) aged 35–54 years and in 105 randomly selected control subjects (46 men, 59 women). Coronary heart disease, defined by symptoms and ECG abnormalities, was 1.2 times higher in male and 3.4 times higher in female diabetic patients than in the controls. In logistic regression analysis (including diabetes, age, body mass index, triglycerides, HDL-cholesterol, non-HDL-cholesterol and hypertension) diabetes showed an independent, significant association to coronary heart disease in women, whereas hypertension was independently related to coronary heart disease in men.Corresponding author.     

Incidence, delay and survival in the Belfast MONICA Project coronary event register

During the 1983-85 period, the Belfast MONICA Project registered coronary events in 2,512 individuals (1,913 men and 599 women). The attack rates in men and women per 1,000 person years were 5.9 and 1.7 respectively, and the corresponding mortality rates were 2.4 and 0.61; both rates were heavily age-dependent. There were statistically significant differences in the age and sex-standardised rates for the 107 electoral wards of the Study. The median delay time from onset to delivery of care was 2 hours 30 minutes and 3 hours 2 minutes for men and women, respectively. Delays were shorter in younger and married individuals, and in those with previous infarctions. Unmarried individuals and those with chronic ischaemic heart disease were at significantly increased risk of pre-care death. Sixty per cent of deaths within 28 days of onset occurred before the patient could be admitted to hospital. Sixty-four per cent of males and 67% of females were alive at 28 days. Manual workers and their spouses had a poorer survival at 28 days. Married men and women were at lowest risk of death in the first 28 days, and this could not be attributed to the effects of age.     

Metacarpal cortical area and risk of coronary heart disease: the Framingham Study

The objective of this study was to determine the relation between bone mass and the incidence of coronary heart disease in women and men. Participants included 2,059 cohort members of the Framingham Study (1,236 women and 823 men aged 47-80 years) who underwent posteroanterior hand radiography and were free from cardiovascular disease at baseline (1967-1970) and who were then followed for 30 years through the end of 1997 for the incidence of coronary heart disease. The incidence of coronary heart disease decreased from 15.65/1,000 person-years among women in the lowest metacarpal cortical area quartile to 11.76/1,000 person-years among women in the highest quartile (p(trend) = 0.03), and the inverse relation persisted after adjustment for confounders (highest vs. lowest quartile of metacarpal cortical area: hazard ratio = 0.73, 95% confidence interval: 0.53, 1.00; p(trend) = 0.03). In contrast, no association was present in men (highest vs. lowest quartile of metacarpal cortical area: hazard ratio = 1.14, 95% confidence interval: 0.84, 1.56; p(trend) = 0.55).     

Physical activity and coronary heart disease in middle-aged and elderly men: the Honolulu Heart Program.

The relationship of physical activity to the development of definite coronary heart disease was examined separately in middle-aged (45-64 years) and elderly men (65-69 years) participating in the Honolulu Heart Program. After 12 years of follow-up, results indicate that increased levels of physical activity reported at study entry were inversely related to the risk of definite coronary heart disease in both age groups. In particular, among those aged 45 to 64 years, the rate of definite coronary heart disease in men who led active life styles was 30 per cent lower than the rate experienced by those who were less active (relative risk, 0.69; 95% confidence interval, 0.53, 0.88). In those older than 64 years, the rate of definite coronary heart disease in active men was less than half the rate experienced by those who led more sedentary life styles (relative risk, 0.43; 95% CI, 0.19, 0.99). These results continued to hold up when controlling for several cardiovascular risk factors and potentially confounding variables, supporting earlier observations that physical activity is beneficial in middle-age, and further suggesting that benefits may extend to the elderly male population as well.