A coronary heart disease risk model for predicting the effect of potent antiretroviral therapy in HIV-1 infected men

BACKGROUND: Many HIV-infected patients on highly active antiretroviral therapy (HAART) experience metabolic complications including dyslipidaemia and insulin resistance, which may increase their coronary heart disease (CHD) risk. We developed a prognostic model for CHD tailored to the changes in risk factors observed in patients starting HAART. METHODS: Data from five cohort studies (British Regional Heart Study, Caerphilly and Speedwell Studies, Framingham Offspring Study, Whitehall II) on 13,100 men aged 40-70 and 114,443 years of follow up were used. CHD was defined as myocardial infarction or death from CHD. Model fit was assessed using the Akaike Information Criterion; generalizability across cohorts was examined using internal-external cross-validation. RESULTS: A parametric model based on the Gompertz distribution generalized best. Variables included in the model were systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, triglyceride, glucose, diabetes mellitus, body mass index and smoking status. Compared with patients not on HAART, the estimated CHD hazard ratio (HR) for patients on HAART was 1.46 (95% CI 1.15-1.86) for moderate and 2.48 (95% CI 1.76-3.51) for severe metabolic complications. CONCLUSIONS: The change in the risk of CHD in HIV-infected men starting HAART can be estimated based on typical changes in risk factors, assuming that HRs estimated using data from non-infected men are applicable to HIV-infected men. Based on this model the risk of CHD is likely to increase, but increases may often be modest, and could be offset by lifestyle changes.     

Contextualising lifestyles: how socially contrasting places in Fife,Scotland influence lay understandings of lifestyle and health behaviours in relation to coronary heart disease

Coronary heart disease (CHD) is a significant public health issue showing persistent geographical health inequalities. However, little attention has focussed on lay perspectives of how contrasting social contexts influence lifestyles and health behaviour in relation to CHD. The aim of this qualitative study is to explore lay perspectives of lifestyle and behaviour in socioeconomically contrasting places, with women and men who had survived a heart attack in Fife, Scotland. This study contributes to knowledge on CHD health inequalities and health promotion, particularly cardiac rehabilitation, emphasising the importance of situating experiences and understandings of health, geographically.     

The relationship between education and risk factors for coronary heart disease

In nine samples of adult populations (2707 males and 2871 females, aged 20–59 years) we studied the relationship between educational level and several lifestyle factors at risk for coronary heart disease (CHD), (i.e., smoking, alcohol consumption, dietary fat intake, sedentary behaviour at work and leisure) and the association between education and certain CHD risk factors (i.e., total cholesterol, HDL-cholesterol, triglycerides, systolic and diastolic blood pressure, body mass index). The data were analyzed separately in samples from North, Central and Southern Italy. The results show that educational level is often associated to the lifestyle factors considered here. This association was positive for both men and women for physical activity at leisure and work stress and only for women with respect to smoking. It was negative for both men and women for alcohol consumption and physical activity at work and for men only for cigarette smoking. The age-adjusted mean levels of the CHD risk factors show some significant differences among subjects with different educational levels, which were not always the same for the three geographical areas. This was with the exception of BMI in females, which appears negatively associated to education in all areas. These differences decreased after adjustments were made for daily cigarette smoking, wine consumption and dietary fat intake. Education seems to play a determining role in lifestyle, however its direct and indirect effects on some major CHD risk factors are somewhat different in areas at different socio-economic conditions.     

Type A behaviour and consumption of an atherogenic diet: no association in the PRIME study

It has previously been suggested that the association between Type A behaviour and coronary heart disease (CHD) may be mediated through diet. This analysis investigates associations between Type A behaviour and diet, with particular focus on foods high in saturated fats and cholesterol (cake, cheese, eggs and fried potatoes), foods high in unsaturated fats (fish and nuts), and fruit and vegetables. The analysis was conducted on data collected from 10,602 men from Northern Ireland and France screened for inclusion in the PRIME cohort study. Type A behaviour was measured using the Framingham Type A Behaviour Patterns Questionnaire, diet was measured using a Food Frequency Questionnaire and various demographic details were also assessed. Levels of Type A behaviour and intakes of all food groups were similar to previous studies. Using regression, Type A behaviour was significantly associated with diet, and specifically with a higher consumption of cheese and vegetables in Northern Ireland, and a higher consumption of cake, fish and vegetables in France. These associations are most plausibly explained as a result of lifestyle, although the possibility of independent associations between Type A behaviour and diet remains. The work is limited by the use of questionnaires, but the findings available suggest that Type A behaviour is unlikely to be associated with the consumption of a diet that has previously been linked to CHD. These findings suggest that any association between Type A behaviour and CHD is unlikely to be mediated through diet.     

Type of gallstones and deaths from stroke and coronary heart disease among cholecystectomized patients

A total of 841 Japanese patients who had undergone cholecystectomy for choleithiasis (550 for cholesterol stones and 291 for pigment stones) from 1951 to 1970 were investigated on death from stroke, coronary heart disease (CHD) and heart disease other than CHD in relation to the type of gallstones. Compared to patients with pigment stones, those having cholesterol stones had a 50% lower risk of dying from stroke which was statistically significant. The findings support the idea that westernization of Japanese diets may be responsible both for the decline in stroke mortality and for the changing pattern of gallstones in this country. The risk of CHD among cholesterol-stone patients was higher, but not significantly so, than that of pigment-stone patients whereas mortality from heart disease other than CHD did not differ much between the two groups. There were, however, few deaths from these diseases and the findings were therefore not conclusive.     

Clustering of risk factors for coronary heart disease. the longitudinal relationship with lifestyle

PURPOSE: The purpose of this study was to investigate whether or not clustering of biological coronary heart disease (CHD) risk factors exists and to investigate the longitudinal relationship between lifestyle parameters (dietary intake, daily physical activity, smoking behaviour, alcohol consumption) and a biological CHD risk factor clustering score. This was defined as belonging to one or more gender specific 'high risk' quartiles for the following CHD risk factors: ratio between total serum cholesterol and high density lipoprotein cholesterol (TC:HDL), mean arterial blood pressure (MABP), body fatness [sum of skinfolds (SSF)], and cardiopulmonary fitness (VO2-max). METHODS: The data were derived from the Amsterdam Growth and Health Study, an observational longitudinal study in which six repeated measurements were carried out over a period of 15 years covering adolescence and young adulthood. The longitudinal relationships were analysed with generalized estimating equations. RESULTS: The results showed significant clustering for the TC:HDL ratio, SSF, and VO(2)-max. MABP was not significantly associated with the other CHD risk factors. Daily physical activity and alcohol consumption (only for males) were both inversely related to the clustering score. None of the other lifestyle parameters showed significant relationships with the clustering score. CONCLUSIONS: Based on this small longitudinal study, it can be stated that during adolescence and young adulthood both daily physical activity and alcohol consumption were related to a healthy CHD risk profile.     

Summary of 'Cholesterol' guideline (first revision) of the Dutch Society of Family Physicians

The revised guidelines on cholesterol of the Dutch College of General Practitioners (DCGP), which closely follow the consensus of the Dutch Institute for Health Care Improvement, provide thresholds for treatment with statins in patients with elevated risks for coronary heart disease (CHD): patients with a history of cardiovascular disease, with an annual CHD risk larger than 2.5-3%, or with a (suspected) hereditary lipid disorder. Unlike the consensus the DCGP guideline advises only to determine a total cholesterol/HDL cholesterol ratio if the accompanying risk table indicates that the patient might fall in the range where drug treatment is indicated. For this purpose an extra column has been added to the table. In patients with a possible hereditary lipid disorder a higher threshold for referral to a specialist is used because moderately raised levels are common in the population and indicate a familial lipid disorder in only part of the cases.     

The impact of medication use in a multicomponent intervention: results from the WISEWOMAN program

PURPOSE: To assess the impact of medication use on improvements in coronary heart disease (CHD) risk among WISEWOMAN participants. DESIGN: Pre-post analysis. SETTING: WISEWOMAN projects operating at the local level in 8 states. SUBJECTS: WISEWOMAN participants with baseline and one-year follow-up data with at least one abnormal risk factor at baseline (N=2385; 24% of women with baseline visits). INTERVENTION: WISEWOMAN provides low-income uninsured women with CHD risk factor screenings, lifestyle interventions, access to medications, and referral services. MEASURES: One-year changes in blood pressure, cholesterol, and 10-year CHD risk by medication status. ANALYSIS: Regression analysis was used to estimate risk factor changes by medication status (newly medicated women, women medicated at baseline, or not medicated women) and quantify the percentage of improvements in risk factors attributed to medication use. RESULTS: Participants experienced statistically significant improvements in systolic (12.6 mm Hg) and diastolic (9.7 mm Hg) blood pressure, total (25.7 mg/dl) and HDL (4.9 mg/dl) cholesterol, and 10-year CHD risk (11.6%). Medication use was responsible for 4% to 5% of the reduction in blood pressure, 32% of the reduction in total cholesterol, 3% of the increase in HDL cholesterol, and 31 % of the reduction in 10-year CHD risk. CONCLUSIONS: Some of the improvements in CHD risk factors can be attributed to medication use; however, the majority of improvements are likely driven by a combination of other factors, including screenings, risk factor counseling, and lifestyle interventions.     

血清尿酸与非高密度脂蛋白胆固醇检测在冠心病预测、评价中的意义

目的分析血清尿酸（UA）、非高密度脂蛋白胆固醇（non-HDL-C）及其他血脂指标在冠心病患者中的变化及意义。方法随机选取冠心病（CHD）患者293例及147例体检健康者（对照组）,测定血清尿酸、血脂,计算non-HDL-C值,采用SPSS软件进行统计学分析。结果CHD组UA、non-HDL-C、甘油三酯（TG）浓度明显高于对照组（P〈0.01）;低密度脂蛋白胆固醇（LDL-C）、脱辅基蛋白B（aPoB）浓度高于对照组（P〈0.05）;载脂蛋白-AI（aPoA-I）、高密度脂蛋白胆固醇（HDL-C）水平显著低于对照组（P〈0.01）;经多元素logistie回归分析发现non-HDL-C与CHD发生关系最密切,其次为UA、TG、LDL-C等。结论non-HDL-C比LDL-C对CHD的发生有更好的预测评价作用。高尿酸血症可能是CHD发生的又一危险因素。     

The effects of statins on stroke and cardiovascular incidence in randomized, placebo-controlled trials with clinical endpoints

In the mortality statistics behind the coronary heart disease and cancer the stroke is the third leading cause of death. The risk factors of stroke and coronary heart disease are similar, but in a recent meta-analysis (Prospective Studies Collaboration) on 450,000 patients from 45 studies didn't find close correlation between the occurrence of stroke and the cholesterol level. In the Multiple Risk Factor Intervention Trial the incidence of haemorrhagic and non-haemorrhagic stroke was analysed separately and a significant correlation has been found between the high cholesterol level and occurrence of the non-haemorrhagic stroke. The great statin trials in a large scale of patients' groups (different cholesterol and risk levels at the inclusion) beside the decline of coronary events proved a decrease in stroke incidence too. The mechanism of action of the statins on stroke is not known: beside the cholesterol lowering effect the so called pleiotropic effects (plaque stabilisation, improvement of endothelial dysfunction and antithrombotic properties) and a direct effect on vascular tone could get importance. The fact that statins could improve the incidence of coronary events with 24-34%, that of stroke with 10-31%, suggests, that this drugs has to be used more frequently in the clinical practice.     

LP(A) and the risk of coronary heart disease

A screening study was performed on 106 children with familial risk for coronary heart disease (CHD) and on matched controls. The two groups differed in several parameters. Children of CHD patients exhibited significantly elevated levels of Lp(a) and total cholesterol, reduced HDL apo A1 and apo A2 and increased values of serum hexuronic acid. These results support the concept that genetic and familial factors contribute to the risk of atherosclerosis.Corresponding author     

Cardiovascular disease and the aging woman: overcoming barriers to lifestyle changes

Coronary heart disease (CHD) is the leading cause of death in women aged 60 years and older, yet 40% of this group believe they are unlikely to have a heart attack. Recent data show that the lack of a low-risk lifestyle may account for approximately 82% of coronary events in women. Underappreciation of CHD risk may prevent aging women from making significant changes in dietary habits, activity levels, and tobacco use to decrease their risk. In addition, many physicians may not treat cardiovascular risk factors aggressively in middle-aged and older women, despite data from primary and secondary prevention trials supporting the efficacy of interventions. This article addresses age-related changes in cardiovascular risk factors in women, with a focus on lifestyle interventions.     

Switching to statins: a challenge for primary care

In 1997, doctors in England received official guidelines on the use of statins (3-hydroxy-3-methylglutaryl coenzyme A inhibitors) for primary and secondary prevention of coronary heart disease (CHD). Six months later we determined the status of patients who had been discharged from a specialist lipid clinic in 1989. 195 patients received questionnaires, with the consent of their general practitioners, regarding morbidity in, the subsequent decade and present medication, and were asked to have their cholesterol checked. Analysis was confined to the 86 with a current cholesterol measurement. Of 61 patients who had been discharged on a regimen of dietary advice and/or medication for primary prevention of CHD, 8 had been changed to a statin and 6 had been started on one. According to the new guidelines, none of these qualified for treatment. Of 25 patients who had been discharged on drugs for secondary prevention, all qualified for a statin but only 14 were receiving one--in 6 cases without achieving the recommended reductions in cholesterol. In many of the patients reviewed, treatment had not been altered to conform with the new guidelines. If hyperlipidaemic patients are to benefit promptly from advances in treatment, one solution might be a central registry that arranged regular tests and reported back to general practitioners. However, since many patients at risk do not have very high cholesterol levels, a coordinated approach to CHD risk factors would be preferable.     

Reduced Mortality Rates after Intensive Statin Therapy in Managed-Care Patients

OBJECTIVE: To evaluate whether intensive statin therapy in a managed-care setting produces greater clinical benefit than more moderate statin use. METHODS: Adults hospitalized for a coronary heart disease (CHD) event were identified from a longitudinal database of pharmaceutical and medical claims. Propensity scores representing a patient's likelihood of receiving statin therapy were calculated. Statin-treated patients were those who received statin therapy within 30 days of hospital discharge after a CHD event, had been supplied with statin therapy for at least 10 days during the follow-up period, and received statin therapy for at least 10 days before the first recurrent CHD event. Standard or intensive statin therapy was identified according to low-density lipoprotein cholesterol reductions expected with statin dose. Patients in the standard and intensive groups were matched by propensity scores to patients not receiving statin therapy after discharge. Patients in the standard statin therapy group were also matched to patients who received intensive statin therapy. Mortality rates after hospital discharge were compared in all matched groups. RESULTS: Patients treated with standard therapy experienced a 32% reduction in risk of death compared with patients not receiving statin therapy (P = 0.003). Patients who received intensive statin therapy after a CHD event experienced a 42% reduction in risk of mortality (P = 0.002) versus those not receiving statin therapy. Compared with standard therapy, intensive statin treatment further reduced the risk of death by 29% (P = 0.020). CONCLUSIONS: High risk CHD patients benefit from intensive statin therapy in a real-world, managed-care cohort, confirming the results of randomized clinical trials.     

老年男性睾酮水平与冠心病发病危险因素的相关性分析

目的探讨老年男性睾水平与冠心病发病危险因素的相关性。方法用化学发光法测定84例经冠状动脉造影证实为冠心病(CHD)组的患者及31例经冠状动脉造影证实无冠状动脉病变的对照组血清睾酮水平,同时测定血清总胆固醇(TC)、甘油三酯(TG)高密度脂蛋白(HDL-C)、低密度脂蛋白(LDL-C)、超敏C反应蛋白(hs-CRP),并调查年龄、体质指数(BMI)、血压、是否吸烟。根据冠状动脉造影检查结果判断狭窄程度并累积积分。结果冠心病组睾酮水平与对照组比较差异有统计学意义[(3.12±1.45)vs(4.58±1.12)μg/L,t=5.071,P=0.000)];CHD组高血压,糖尿病的比例高于对照组(P均﹤0.05)。多元Logistic回归分析显示,血清睾酮为CHD独立危险因素;血清睾酮与CHD冠状动脉狭窄程度呈负相关。结论血清睾酮水平降低可能也是老年男性冠心病发病的危险因素之一,在预防老年男性冠心病危险因素的同时也应关注血清睾酮降低的防治。     

Application of medical guidelines for the prescription of statins

BACKGROUND: The efficacy of statins to prevent coronary heart disease (CHD) is well documented. This class of lipid-lowering drugs is now widely prescribed and was demonstrated to be cost effective in high risk patients. OBJECTIVE: To assess the appropriateness of statins use, regarding initiation and follow-up of the treatment, as compared to the guidelines elaborated in 1996 by National Agency for the Development of Medical Evaluation (ANDEM). These guidelines were based on stratification of patients according to cardiovascular risk. METHODS: Two groups of patients living in Ile-de-France region were defined, using Health Insurance computer database, on reimbursements. The first group named "new users" included patients in whom statin therapy was initiated during March 2000. The second group named "long term users" included patients who have been treated by statin therapy for one year or more. A sample of patients were randomly selected among these two groups. Trained Health Insurance advisors analyzed in depth the patients medical history and diet. All biological results were recorded and a complete history of medical therapy was assessed for each patient. An algorithm allowed the advisor to rate for nonadherence according to French medical guidelines. RESULTS: "New users": the random sample consisted of 460 patients, among whom 398 (87%) were free of CHD in whom the nonadherence rate was 72.4% (68.0% to 76.8%). Nonadherence concerned: LDL cholesterol level not tested (32%) and/or absence of prior fat-free diet (37%) and/or LDL cholesterol value before drug therapy was below the guidelines/threshold. "Long term users": the random sample consisted of 582 patients, among whom 381 (65%) were free of CHD. The nonadherence rate was 71.1% (66.5% to 75.7%). In addition, the nonadherence rate for patients in secondary prevention was 82.1% (79.7% to 84.6%) respectively, corresponding to: LDL cholesterol level not tested (41% and 34%); and/or no change dietary (18% and 12%); and/or unreach the LDL-C target level (24% and 45%). CONCLUSION: This study shows that the implementation of guidelines needs to be improved in clinical practice.     

High-density lipoprotein subclass and particle size in coronary heart disease patients with or without diabetes

ABSTRACT: BACKGROUND: A higher prevalence of coronary heart disease (CHD) in people with diabetes. We investigated the high-density lipoprotein (HDL) subclass profiles and alterations of particle size in CHD patients with diabetes or without diabetes. METHODS: Plasma HDL subclasses were quantified in CHD by 1-dimensional gel electrophoresis coupled with immunodetection. RESULTS: Although the particle size of HDL tend to small, the mean levels of low density lipoprotein cholesterol(LDL-C) and total cholesterol (TC) have achieved normal or desirable for CHD patients with or without diabetes who administered statins therapy. Fasting plasma glucose (FPG), triglyceride (TG), TC, LDL-C concentrations, and HDL3 (HDL3b and 3a) contents along with Gensini Score were significantly higher; but those of HDL-C, HDL2b+prebeta2, and HDL2a were significantly lower in CHD patients with diabetes versus CHD patients without diabetes; The prebeta1-HDL contents did not differ significantly between these groups. Multivariate regression analysis revealed that Gensini Score was significantly and independently predicted by HDL2a, and HDL2b+prebeta2. CONCLUSIONS: The abnormality of HDL subpopulations distribution and particle size may contribute to CHD risk in diabetes patients. The HDL subclasses distribution may help in severity of coronary artery and risk stratification, especially in CHD patients with therapeutic LDL, TG and HDL levels.     

"Sneaky disease": the body and health knowledge for people at risk for coronary heart disease in Ontario, Canada

The contribution of modifiable risk factors to the prevalence of coronary heart disease (CHD) has been well documented in the literature. A focus group component of a cardiovascular risk reduction project, The Community Outreach in Heart Health and Risk Reduction Trial was designed to explore issues that facilitate or constrain individual efforts to implement changes to health behaviours. Eight focus groups were conducted in urban, northern and rural sites in Ontario, Canada. In this article, we elaborate on the difficulties all group members experienced as they attempted to interpret their personal candidacy for CHD. For many participants, CHD was an undetectable or "sneaky disease" in its earlier stages, thus coronary risk was to them an abstract concept that could not ordinarily be detected through sensory perception. Participants drew on three possible strategies to determine their candidacy for CHD: they cognitively engaged in weighing risks, they relied on the interpretive powers of medical hermeneutics, or they waited for "the big event". The findings suggest that lay understandings of the body and health differ from those of health professionals and educators, and that lay understandings differ according to SES and gender. This has implications for health literacy and must be considered in devising strategies for health education.     

Lost Therapeutic Benefit of Delayed Low-Density Lipoprotein Cholesterol Control in Statin-Treated Patients and Cost-Effectiveness Analysis of Lipid-Lowering Intensification

ObjectivesAttainment of low-density lipoprotein cholesterol (LDL-C) therapeutic goals in statin-treated patients remains suboptimal. We quantified the health economic impact of delayed lipid-lowering intensification from an Australian healthcare and societal perspective.MethodsA lifetime Markov cohort model (n = 1000) estimating the impact on coronary heart disease (CHD) of intensifying lipid-lowering treatment in statin-treated patients with uncontrolled LDL-C, at moderate to high risk of CHD with no delay or after a 5-year delay, compared with standard of care (no intensification), starting at age 40 years. Intensification was tested with high-intensity statins or statins + ezetimibe. LDL-C levels were extracted from a primary care cohort. CHD risk was estimated using the pooled cohort equation. The effect of cumulative exposure to LDL-C on CHD risk was derived from Mendelian randomization data. Outcomes included CHD events, quality-adjusted life-years (QALYs), healthcare and productivity costs, and incremental cost-effectiveness ratios (ICERs). All outcomes were discounted annually by 5%.ResultsOver the lifetime horizon, compared with standard of care, achieving LDL-C control with no delay with high-intensity statins prevented 29 CHD events and yielded 30 extra QALYs (ICERs AU$13 205/QALY) versus 22 CHD events and 16 QALYs (ICER AU$20 270/QALY) with a 5-year delay. For statins + ezetimibe, no delay prevented 53 CHD events and gave 45 extra QALYs (ICER AU$37 271/QALY) versus 40 CHD events and 29 QALYs (ICER of AU$44 218/QALY) after a 5-year delay.ConclusionsDelaying attainment of LDL-C goals translates into lost therapeutic benefit and a waste of resources. Urgent policies are needed to improve LDL-C goal attainment in statin-treated patients.     

Effectiveness of behaviour change techniques on lifestyle interventions of patients with a high risk of developing cardiovascular disease. Using a qualitative approach

This study aimed to identify key active ingredients on the maintenance of behaviour change for lifestyle interventions of patients with a high risk of developing cardiovascular disease (CVD) who participated in a MOtiVational intErviewing InTervention (MOVE IT) randomised control trial (RCT). A process evaluation was carried out using focus groups. Twenty‐six participants of the MOVE IT RCT were purposively recruited and split into six focus groups. Four groups had attended six or more sessions of the intensive phase (completers) and two groups had withdrawn before the end of the intensive phase or had not attended any sessions (non‐completers). Focus groups were audio recorded, transcribed verbatim and analysed inductively using thematic analysis. Three overall themes were generated from the six focus groups: (a) long‐term benefits from diet and physical activity education, (b) group versus individual structure and adherence and (c) impact on health beliefs and risk of CVD. A fourth theme was generated from the two groups of non‐completers only: (d) need for professional rapport building and feedback. We found that the key active ingredients for effective behavioural change in lifestyle interventions are having well‐developed rapport between facilitators and patients; and providing alternative forms of feedback to encourage maintenance of behaviour change. Furthermore, such programmes also need to have established and strong relationships with associated health professionals (i.e. the General Practitioner) to increase participation and maintenance of engagement.