A cardiovascular life history. A life course analysis of the original Framingham Heart Study cohort.

AIMS The objective of this paper is to measure the potential burden of cardiovascular disease within the original Framingham Heart Study cohort by transforming its well-described epidemiological measures into time-based health policy measures, such as life years lost to or lived with the disease. METHODS AND RESULTS We constructed multi-state life tables of the Framingham Heart Study cohort to calculate dwelling times with a history of cardiovascular disease. Age-specific probabilities determined transitions from healthy through disease to death. For this synthetic cohort, from age 50 men (women) live on average 26 (32) years; 20 (26) free of cardiovascular disease. Allowing occupancy of more than one disease state, 50-year-old males (females) live 2 X 9 (1 X 2) years with a history of myocardial infarction, 0 X 93 (1 X 2) with a history of stroke, and 0 X 67 (0 X 93) with congestive heart failure. Having ever suffered acute myocardial infarction, stroke or congestive heart failure, life expectancy is reduced by 9 (13), 12 (15) or 16 (16) years, respectively in 60-year-old men (women). CONCLUSIONS Transforming occurrence probabilities into time-based health measures, the prevalence of cardiovascular disease is remarkable: from age 50, 20% of remaining life expectancy is lived with the disease. Such measures are integral to appropriate health planning and assessment of the potential population health value of various treatment and prevention strategies.     

Plasma renin and risk of cardiovascular disease and mortality: the Framingham Heart Study.

AIMS: Previous studies relating plasma renin to cardiovascular disease (CVD) and mortality yielded conflicting results. We related plasma renin to incidence of CVD and mortality in 3408 individuals (mean age 59; 53% women) and in a hypertensive subset (n = 1413). METHODS AND RESULTS: On follow-up (mean 7.1 years), 176 participants (122 hypertensives) developed CVD and 215 individuals (127 hypertensives) died. Overall, log-renin was associated with mortality [multivariable-adjusted hazards ratio (HR) per SD increment: in whole sample, 1.14, 95% confidence interval (CI) 1.00-1.30, P = 0.046; hypertensives, 1.16, 95% CI 1.00-1.35, P = 0.046], but relations varied over time (P < 0.02). Log-renin was associated with mortality at 2.5 years of follow-up (HR per SD increment: whole sample at 2.5 years, 1.23, 95% CI 1.04-1.45; hypertensives at 2 years, 1.28, 95% CI 1.06-1.54), but not during longer follow-up (HR per SD increment at 5 years: whole sample, 1.02, 95% CI 0.80-1.29; hypertensives, 0.98, 95% CI 0.74-1.30). The time-dependent relation of renin and mortality risk was maintained upon excluding participants with prevalent CVD. Renin was not associated with CVD incidence (HR per SD increment log-renin: whole sample, 0.99, 95% CI 0.85-1.14; hypertensives, 0.96, 95% CI 0.82-1.12). CONCLUSION: Higher plasma renin was associated with greater short-term mortality but not with CVD incidence in the community.     

Smoking and atherosclerotic cardiovascular disease in women with lower levels of serum cholesterol

This cohort study of Koreans examines the relationship between smoking on atherosclerotic cardiovascular disease (ASCVD) and whether serum levels of total cholesterol modify the impact of smoking on ASCVD.

A 10-year prospective cohort study was carried out on 234,399 Korean women, ranging 40–69 years of age who received health insurance from the National Health Insurance Corporation and had a medical evaluation in 1993. The main outcome measures were hospital admissions and deaths from ischemic heart disease (IHD), cerebrovascular disease (CVD), and total ASCVD.

At baseline, 13,696 (5.8%) were current smokers and 105,755 (45.1%) had a total cholesterol <200 mg/dl. Between 1994 and 2003, 4534 IHD (176/100,000 person year), 7961 CVD (310/100,000 person year), and 2418 other ASCVD events (94/100,000 person year) occurred. In multivariate Cox proportional hazard models controlling for age, hypertension, hypercholesterolemia, diabetes and alcohol drinking, current smoking increased the risk of IHD [hazard ratio (HR) = 1.7 (95% CI: 1.5–1.9)], CVD [HR = 1.6 (95% CI: 1.5–1.6)], and total ASCVD events [HR = 1.6 (95% CI: 1.5–1.7)]. Throughout the range of serum cholesterol levels, current smoking significantly increased the risk of myocardial infarction and CVD, but not angina pectoris. There was no evidence of an interaction between smoking and serum cholesterol (p for interaction = 0.469, 0.612, and 0.905 for IHD, CVD, and total ASCVD, respectively).

This study demonstrated that smoking was a major independent risk factor for IHD, CVD and ASCVD in Korean women. A low cholesterol level confers no protective benefit against smoking-related ASCVD.     

Changes in all-cause and cardiovascular disease mortality in three different Finnish population cohorts with and without diabetes

Background

We aimed to assess changes in cardiovascular (CVD) and all-cause mortality among diabetic and non-diabetic individuals between three large study cohorts with baseline assessments of 10 years apart and followed up for 10 years.

Methods

Six population surveys were carried out in 1972, 1977, 1982, 1987, 1992 and 1997 in Finland. For the analyses we combined the 1972 and 1977 cohorts (cohort 1), the 1982 and 1987 cohorts (cohort 2) and similarly also the 1992 and 1997 cohorts (cohort 3).

Results

Age-adjusted hazard ratio (HR) of all-cause mortality and CVD in men without diabetes showed that both had a statistically significant decreased risk of all-cause mortality compared to the first cohort. No statistically significant changes in all-cause mortality were observed in men and women with diabetes between the latter two cohorts compared with the first after controlling for several covariates. In both men and women without diabetes, cohort 2 (men, HR = 0.65; 95% CI 0.51–0.82; women, HR = 0.54; 95% CI 0.32–0.89) and cohort 3 (men, HR = 0.32; 95% CI 0.22–0.47; women, HR = 0.31; 95% CI 0.14–0.68) showed a statistically significant decreased risk of CVD mortality compared to cohort 1. Age-adjusted HRs in regard to CVD mortality in men (HR = 0.22; 95% CI 0.07–0.69) and women (HR = 0.22; 95% CI 0.05–0.99) with diabetes of cohort 3 were statistically significantly lower than in cohort 1.

Conclusions

There seems to be a decrease in CVD mortality in people with diabetes indicating that treatment of diabetes and cardiovascular risk factors in diabetes patients may have improved during the last decade.     

Bupropion SR for smoking cessation in smokers with cardiovascular disease: a multicentre, randomised study.

AIMS: To investigate the safety and efficacy of bupropion sustained release (bupropion SR) in promoting abstinence from smoking in subjects with cardiovascular disease (CVD). METHODS: Six hundred twenty-nine subjects with CVD who smoked >/=10 cigarettes/day were randomised in a double-blind, multicentre study to receive bupropion SR (150 mg twice daily) or placebo for 7 weeks, with a follow-up of 52 weeks. Primary efficacy endpoint: continuous abstinence from smoking from weeks 4 to 7. Secondary endpoints: continuous abstinence (weeks 4-12, 4-26 and 4-52) and weekly point prevalence abstinence. All participants received brief motivational support. Safety was evaluated throughout the study. RESULTS: Continuous smoking abstinence rates from weeks 4 to 7 were significantly higher in subjects receiving bupropion SR compared with placebo (43 vs. 19%, odds ratio [OR]=3.27, 95% confidence interval [CI] 2.24-4.84; P<0.001). Continuous abstinence rates from weeks 4 to 26 and 4 to 52 continued to be more than double for bupropion SR compared with placebo (27 vs. 11%; 22 vs. 9%, P<0.001). Weekly point prevalence abstinence was significantly higher for participants who received bupropion SR compared with placebo at weeks 3, 7, 26 and 52 (P<0.001). In both groups, there were no clinically significant changes in blood pressure and heart rate throughout the treatment phase. Overall, 6% of the participants (n=36) discontinued study medication due to an adverse event (bupropion SR, n=17; placebo, n=19). CONCLUSIONS: After 7 weeks of bupropion SR treatment, more than twice as many smokers with CVD had quit smoking at 1 year compared with placebo. The safety profile of bupropion SR was similar to that previously observed in general smoking populations.     

Lifestyle and cardiovascular disease in middle-aged British men: the effect of adjusting for within-person variation.

AIMS: To examine the effect that within-person variation has on the estimated risk associations between cigarette smoking, physical inactivity, and increased body mass index (BMI) and the development of cardiovascular disease (CVD) in middle-aged British men. METHODS AND RESULTS: In total, 6452 men aged 40-59 with no prior evidence of CVD were followed for major CVD events (fatal/non-fatal myocardial infarction or stroke) and all-cause mortality over 20 years; lifestyle characteristics were ascertained at regular points throughout the study. A major CVD event within the first 20 years was observed in 1194 men (18.5%). Use of baseline assessments of cigarette smoking and physical activity in analyses resulted in underestimation of the associations between average cumulative exposure to these factors and major CVD risk. After correction for within-person variation, major CVD rates were over four times higher for heavy smokers (> or =40 cigarettes/day) compared with never smokers and three times higher for physically inactive men compared with moderately active men. Major CVD risk increased by 6% for each 1 kg/m(2) increase in usual BMI. If all men had experienced the risk levels of the men who had never regularly smoked cigarettes, were moderately active, and had a BMI of < or =25 kg/m(2) (6% of the population), 66% of the observed major CVD events would have been prevented or postponed (63% before adjustment for within-person variation). Adjustment for a range of other risk factors had little effect on the results. Similar results were obtained for all-cause mortality. CONCLUSION: Failure to take account of within-person variation can lead to underestimation of the importance of lifestyle characteristics in determining CVD risk. Primary prevention through lifestyle modification has a great preventive potential.     

Association of body mass index with mortality in cardiovascular disease: New insights into the obesity paradox from multiple perspectives

Over the past 4 decades, prevalence of obesity has increased rapidly at both the national and global level and presents a major public health challenge. Obesity is associated with increased risk of morbidity from cardiovascular diseases. Data suggesting that the presence of obesity may be protective in individuals with clinically manifest cardiovascular disease have led to discussion of an “obesity paradox”, stirring controversy and leading to unclear messaging regarding the true health risks of excess weight. This review explores the relationship between obesity and fatal and non-fatal outcomes in patients with prevalent cardiovascular disease and offers novel insights into the obesity paradox.     

季节变化与心血管病人死亡关系调查

目的:调查我科住院心血管病人死亡与季节的关系。方法:查阅1993年1月～2004年12月12年来在我科住院死亡的269例病人资料,调查主要的5个病种死亡的季节规律性。结果:(1)季节性:心血管病人冬季死亡率最高,占36.8%(99/269,P<0.01),其他依次为春、秋、夏季;(2)冬季死亡病种:冠心病(CHD)死亡率最高,为79例,占79.8%(P<0.01),其他依次为高血压,主动脉夹层;(3)冠心病:174例CHD死亡患者中,冬季死亡率最高,为79例,占45.4%(P<0.01),其他依次是秋、春、夏季;(4)高血压:在41例高血压死亡病例中,20例死于春季,占48.8%,死亡率最高(P<0.01),其他依次是冬、秋、夏季;(5)其他:风心病15例,心肌病13例死亡病例中均以夏季死亡率最高,分别占46.7%,53.8%(P<0.01),其他依次为秋、冬、春季。结论:心血管病人的死亡率与季节变化相关,要根据其规律性,做好防治工作,降低死亡率。     

12年住院心血管病人死亡趋势调查

目的:分析我院住院心血管病人死亡率趋势。方法:查阅1993年1月至2004年12月12年来在我科住院死亡病人的资料,并进行统计分析。结果:(1)12年来住院病人总数呈上升趋势,死亡率呈下降趋势;(2)在269例死亡病例中,男性死亡率高于女性(P<0.001);(3)在269例死亡病例中,以≥80岁年龄段死亡率最高(P<0.001);(4)住院死亡率,以冠心病及夹层动脉瘤最高,分别达到5.78%,5.5%,两者无显著差异(P>0.05),但冠心病的死亡率较之高血压、风心病、心脏病的显著增加(P<0.001)。结论:12年来昆明地区心血管病人住院总数量上升,反映发病率增加,但死亡率呈下降趋势,说明医疗技术的进步和成绩的显著。     

Bupropion for smokers hospitalized with acute cardiovascular disease

Purpose

Smoking cessation after myocardial infarction reduces cardiovascular mortality, but many smokers cannot quit despite state-of-the-art counseling intervention. Bupropion is effective for smoking cessation, but its safety and efficacy in hospitalized smokers with acute cardiovascular disease is unknown.

Methods

A five-hospital randomized double-blind placebo-controlled trial assessed the safety and efficacy of 12 weeks of sustained-release bupropion (300 mg) or placebo in 248 smokers admitted for acute cardiovascular disease, primarily myocardial infarction and unstable angina. All subjects had smoking counseling in the hospital and for 12 weeks after discharge. Cotinine-validated 7-day tobacco abstinence, cardiovascular mortality, and new cardiovascular events were assessed at 3 months (end-of-treatment) and 1 year.

Results

Validated tobacco abstinence rates in bupropion and placebo groups were 37.1% vs 26.8% (OR 1.61, 95% CI, 0.94-2.76; P=.08) at 3 months and 25.0% vs 21.3% (OR, 1.23, 95% CI, 0.68-2.23, P=.49) at 1 year. The adjusted odds ratio, after controlling for cigarettes per day, depression symptoms, prior bupropion use, hypertension, and length of stay, was 1.91 (95% CI, 1.06-3.40, P=.03) at 3 months and 1.51 (95% CI, 0.81-2.83) at 1 year. Bupropion and placebo groups did not differ in cardiovascular mortality at 1 year (0% vs 2%), in blood pressure at follow-up, or in cardiovascular events at end-of-treatment (16% vs 14%, incidence rate ratio [IRR]1.22 (95% CI: 0.64-2.33) or 1 year (26% vs 18%, IRR 1.56, 95% CI 0.91-2.69).

Conclusions

Bupropion improved short-term but not long-term smoking cessation rates over intensive counseling and appeared to be safe in hospitalized smokers with acute cardiovascular disease.     

Cardiorespiratory fitness and mortality in diabetic men with and without cardiovascular disease

We assessed joint associations of cardiorespiratory fitness and diabetes, cardiovascular disease (CVD), or both with all-cause mortality. High-fitness eliminated mortality risk in diabetes (P < 0.001) and halved risk of death in diabetes/CVD (P < 0.001). Fitness was a potent effect modifier in the association of diabetes and CVD to mortality.     

Diet and lifestyle habits: Association with cardiovascular disease indices in a Nigerian sub-population

Background

There is inadequate evidence regarding the pattern of unhealthy lifestyle behaviours in Nigeria hence the aim of this study was to assess the pattern of lifestyle-related habits that predispose to risk of cardiovascular disease (CVD) indices in a Nigerian population.

Cardiovascular events in type 2 diabetes: comparison with nondiabetic individuals without and with prior cardiovascular disease. 10-year follow-up of the Hoorn Study.

AIMS: We questioned whether prior cardiovascular disease has the same impact on risk of cardiovascular events as type 2 diabetes, and whether this differed between men and women. METHODS AND RESULTS: To address these issues we compared the 10-year risk of cardiovascular events among 208 Caucasian individuals with diabetes to that of 2253 Caucasian individuals without diabetes, in a population-based cohort study. Gender significantly modified the association between type 2 diabetes and cardiovascular events (p=0.01). The hazard ratio of cardiovascular events associated with the presence of diabetes was higher in women (adjusted hazard ratio, 1.8; 95% CI, 1.2 to 2.7) than in men (adjusted hazard ratio, 1.3; 0.9 to 2). As compared to men without diabetes but with prior cardiovascular disease, risk of cardiovascular events was significantly lower in men with diabetes but without prior cardiovascular disease (adjusted hazard ratio, 0.5; 0.3 to 0.9). In contrast, this risk was equal in women with diabetes but without prior cardiovascular disease and women without diabetes but with prior cardiovascular disease (adjusted hazard ratio, 1.0; 0.6 to 1.7; P for interaction between gender and diabetes=0.05). CONCLUSIONS: Women with diabetes but without prior cardiovascular disease have a risk of cardiovascular events that is similar to that of women without diabetes but with prior cardiovascular disease, whereas in men the presence of prior cardiovascular disease conferred a higher risk. These data emphasise the necessity of aggressive treatment of cardiovascular risk factors in women with type 2 diabetes.     

Impact of impaired fasting glucose on cardiovascular disease: the Framingham Heart Study.

OBJECTIVES: We sought to determine whether impaired fasting glucose (IFG) predicts cardiovascular disease (CVD) events. BACKGROUND: It is unclear which glucose threshold should define prediabetes. We compared the 1997 and 2003 American Diabetes Association (ADA) definitions of IFG to predict CVD. METHODS: Framingham offspring participants free of CVD, categorized by the 1997 ADA IFG definition (fasting plasma glucose 110 to 125 mg/dl; 6.1 to 6.9 mmol/l) or the 2003 definition (100 to 125 mg/dl; 5.6 to 6.9 mmol/l), were followed from 1983 to 2004. Pooled logistic regression was used to calculate multivariable-adjusted odds ratios (ORs) for incident coronary heart disease (CHD; 291 events) or CVD (423 events). RESULTS: Four-year CHD event rates among women were 1.3% (100 to 109 mg/dl), 2.3% (110 to 125 mg/dl), and 2.9% (diabetes); whereas corresponding rates in men were 2.9%, 3.0%, and 8.7%. For the 2003 IFG definition, the OR for CHD among women was 1.7 (95% confidence interval [CI] 1.0 to 3.0, p = 0.048), whereas for the 1997 IFG definition, the OR for CHD in women was 2.2 (95% CI 1.1 to 4.4, p = 0.02), which was almost as high as for women with diabetes (OR 2.5, 95% CI 1.2 to 5.2, p = 0.01). For CVD, only the 1997 IFG definition yielded significantly greater odds of CVD in women (OR 2.1, 95% CI 1.2 to 3.6, p = 0.01). Men were not at increased odds of developing CVD or CHD by either definition. CONCLUSIONS: In women, both IFG definitions were associated with increased CHD risk, whereas neither IFG definition identified men at increased short-term risk for CHD or CVD. The finding that women with FPG 110 to 125 mg/dl had similar CHD risk compared with women with diabetes suggests that CHD risk in women may be elevated at a lower glucose level than for men.     

The Systolic Blood Pressure Difference Between Arms and Cardiovascular Disease in the Framingham Heart Study

Background

An increased interarm systolic blood pressure difference is an easily determined physical examination finding. The relationship between interarm systolic blood pressure difference and risk of future cardiovascular disease is uncertain. We described the prevalence and risk factor correlates of interarm systolic blood pressure difference in the Framingham Heart Study (FHS) original and offspring cohorts and examined the association between interarm systolic blood pressure difference and incident cardiovascular disease and all-cause mortality.

Methods

An increased interarm systolic blood pressure difference was defined as ≥10 mm Hg using the average of initial and repeat blood pressure measurements obtained in both arms. Participants were followed through 2010 for incident cardiovascular disease events. Multivariable Cox proportional hazards regression analyses were performed to investigate the effect of interarm systolic blood pressure difference on incident cardiovascular disease.

Results

We examined 3390 (56.3% female) participants aged 40 years and older, free of cardiovascular disease at baseline, mean age of 61.1 years, who attended a FHS examination between 1991 and 1994 (original cohort) and from 1995 to 1998 (offspring cohort). The mean absolute interarm systolic blood pressure difference was 4.6 mm Hg (range 0-78). Increased interarm systolic blood pressure difference was present in 317 (9.4%) participants. The median follow-up time was 13.3 years, during which time 598 participants (17.6%) experienced a first cardiovascular event, including 83 (26.2%) participants with interarm systolic blood pressure difference ≥10 mm Hg. Compared with those with normal interarm systolic blood pressure difference, participants with an elevated interarm systolic blood pressure difference were older (63.0 years vs 60.9 years), had a greater prevalence of diabetes mellitus (13.3% vs 7.5%,), higher systolic blood pressure (136.3 mm Hg vs 129.3 mm Hg), and a higher total cholesterol level (212.1 mg/dL vs 206.5 mg/dL). Interarm systolic blood pressure difference was associated with a significantly increased hazard of incident cardiovascular events in the multivariable adjusted model (hazard ratio 1.38; 95% CI, 1.09-1.75). For each 1-SD-unit increase in absolute interarm systolic blood pressure difference, the hazard ratio for incident cardiovascular events was 1.07 (95% CI, 1.00-1.14) in the fully adjusted model. There was no such association with mortality (hazard ratio 1.02; 95% CI 0.76-1.38).

Conclusions

In this community-based cohort, an interarm systolic blood pressure difference is common and associated with a significant increased risk for future cardiovascular events, even when the absolute difference in arm systolic blood pressure is modest. These findings support research to expand clinical use of this simple measurement.