Fibrinogen in relation to personal history of prevalent hypertension, diabetes, stroke, intermittent claudication, coronary heart disease, and family history: the Scottish Heart Health Study.

OBJECTIVE--To determine the relations of plasma fibrinogen to family history of premature heart disease, personal history of hypertension, diabetes, stroke, coronary heart disease, and to presence of intermittent claudication. DESIGN--Random population survey across 22 local government districts in Scotland. PARTICIPANTS--10,359 men and women aged 40 to 59 years. Plasma fibrinogen was measured in 8824. MAIN OUTCOME MEASURE--Plasma fibrinogen concentration. RESULTS--Persons with a family history of heart disease or a personal history of high blood pressure, diabetes, stroke, or presence of intermittent claudication all had higher plasma fibrinogen concentrations than those without. When compared with participants without cardiovascular or related disease (men: 2.27 (SE = 0.01) g/l, n = 3367; women 2.34 (0.01) g/l, n = 3096), predefined cases of either myocardial infarction (men: 2.51 (0.02) g/l, n = 248; women: 2.63 (0.04) g/l, n = 72) or angina (men: 2.45 (0.02) g/l, n = 394; women: 2.50 (0.02) g/l, n = 398) had significantly higher plasma fibrinogen concentrations (p < 0.001). After adjustment for 10 other coronary risk factors, there was a noticeable linear trend in the odds ratios for myocardial infarction across all quartiles (quarters) of plasma fibrinogen concentrations in both sexes. Similarly, the risk of angina increased linearly with increasing fibrinogen concentrations, although the test for a linear trend was NS among women. CONCLUSIONS--This large population study confirms that plasma fibrinogen is not only a risk factor for coronary heart disease and stroke, but it is also raised with family history of premature heart disease and with personal history of hypertension, diabetes, and presence of intermittent claudication.     

Treatment of older persons with hypercholesterolemia with and without cardiovascular disease

Hypercholesterolemia is a risk factor for new coronary events in older men and women. Secondary prevention trials have demonstrated in persons with coronary artery disease (CAD) and hypercholesterolemia that statin drugs reduced in older persons all-cause mortality, cardiovascular mortality, coronary events, coronary revascularization, stroke, and intermittent claudication. Statins have also been shown to slow progression of coronary atherosclerotic plaques in persons with CAD, to reduce restenosis after coronary stent implantation, and to decrease myocardial ischemia in persons with CAD. Older men and women with CAD, prior atherothrombotic brain infarction, peripheral arterial disease, or extracranial carotid arterial disease and a serum low-density lipoprotein (LDL) cholesterol level higher than 125 mg/dl despite diet should be treated with statin drug therapy to lower the serum LDL cholesterol level below 100 mg/dl. Primary prevention trials have shown that statins were also effective in reducing cardiovascular events in older persons with hypercholesterolemia. On the basis of data from the Air Force/Texas Coronary Atherosclerosis Prevention Study, the physician should consider using statins in persons aged 65-80 years without cardiovascular disease with a serum LDL cholesterol level above 130 mg/dl and serum high-density lipoprotein cholesterol level below 50 mg/dl.     

Cholesterol 2001. Rationale for lipid-lowering in older patients with or without CAD

Statin treatment of men and women age > or = 50 with coronary artery disease (CAD) and hypercholesterolemia reduces the risk of all-cause mortality, cardiovascular mortality, coronary events, coronary revascularization, stroke, and intermittent claudication. The target serum low-density lipoprotein (LDL) cholesterol level is < 100 mg/dL in older patients with CAD, prior stroke, peripheral arterial disease, or extracranial carotid arterial disease and serum LDL cholesterol > 125 mg/dL despite diet therapy. Statins are also effective in reducing cardiovascular events in older persons with hypercholesterolemia but without cardiovascular disease. Consider using statins in patients age 50 to 80 without cardiovascular disease, serum LDL cholesterol > 130 mg/dL, and serum high-density lipoprotein (HDL) cholesterol < 50 mg/dL.     

IgE and cardiovascular disease. Results from a population-based study

Because previous reports have suggested that IgE-mediated events may lead to both platelet activation and arterial spasm, a population-based study of 262 men and 315 women, aged 38 to 82, was conducted to investigate the association of serum IgE levels with myocardial infarction, stroke, and noninvasively diagnosed large-vessel peripheral arterial disease. In men with previous myocardial infarction, previous stroke, or current large-vessel peripheral arterial disease, geometric mean serum IgE levels were increased 119 percent, 164 percent, and 78 percent, respectively. These associations were statistically significant (p less than 0.05). Because IgE was positively or inversely correlated with several traditional cardiovascular disease risk factors, logistic regression was used to evaluate the independent association of IgE with any cardiovascular disease (myocardial infarction, stroke, or large-vessel peripheral arterial disease). In a model including age, cigarette smoking, fasting plasma glucose level, diastolic blood pressure, and low-density lipoprotein cholesterol level as covariates, IgE was positively and independently associated with any cardiovascular disease (p = 0.03). Similar evaluations in women revealed no correlation between IgE and cardiovascular disease by either univariate or multivariable analysis. These data indicate that IgE may be an independent marker for cardiovascular disease in men, and thus suggest IgE-mediated events may play a role in the pathogenesis of cardiovascular disease.     

Male-type fat distribution is associated with cardiovascular risk factors and the prevalence of cardiovascular disease in noninsulin-treated diabetics

Abdominal fat distribution estimated by the waist/hip ratio (WHR) was studied in 85 subjects (55 men, 30 women) with treated noninsulin-dependent diabetes mellitus (NIDDM), and its association with cardiovascular disease and cardiovascular risk factors was analyzed. In men, WHR was highly correlated with the body mass index (BMI; r = 0.697), but this was not true in women (r = 0.091). In men, WHR was significantly and positively correlated with mean diastolic blood pressure (DBP) level. In women, this correlation was also positive, but of lesser degree. Fasting plasma insulin was highly correlated with BMI and WHR in men, but not in women. In both sexes, WHR was positively correlated with fasting serum triglyceride and negatively correlated with serum high-density lipoprotein cholesterol. In addition, mean WHR, but not BMI, was significantly greater in subjects with cardiovascular disease (positive electrocardiographic signs and/or history of angina, myocardial infarction, stroke, intermittent claudication).     

Haemostatic factors and prediction of ischaemic heart disease and stroke in claudicants

Thrombotic risk factors may be important in determining cardiovascular outcome in patients with symptomatic peripheral arterial disease. A cohort study with a 6-year follow-up period was established to determine the relationships between haemostatic and rheological factors and incident ischaemic heart disease (IHD) and stroke events in patients with peripheral arterial disease. A consecutive series of 607 patients with intermittent claudication was examined between 1989 and 1990 at the Peripheral Vascular Clinic, Royal Infirmary of Edinburgh. Main outcome measures were combined fatal and non-fatal stroke, non-fatal myocardial infarction (MI), coronary death and total coronary events. A total of 210 patients died during follow-up. 203 patients did not experience a vascular event or deterioration of limb ischaemia. Median levels of fibrinogen, von Willebrand factor (VWF), tissue plasminogen activator (t-PA) antigen, fibrin D-dimer and whole blood viscosity were significantly higher in those who experienced an event compared with those who did not. After adjusting for age and sex, fibrin D-dimer was significantly associated with risk of non-fatal myocardial infarction (RR 1.50, 95% CI 1.09–2.06, P 0.01). Both fibrinogen and fibrin D-dimer were associated with risk of total coronary events (P 0.05). The risk of stroke was related to baseline levels of t-PA antigen (RR 1.87, 95% CI 1.04–3.34, P 0.05) and whole blood viscosity (RR 1.33, 95% CI 1.07–1.65, P 0.01). All the relationships became weaker and statistically non-significant after further adjustment for cigarette smoking, systolic blood pressure, glucose and baseline IHD. The associations of these factors to IHD and stroke may therefore be partly related to cardiovascular risk factors, but are likely to be important in the pathogenesis of future atherothrombotic events in subjects with peripheral arterial disease.     

5-year incidence of atherosclerotic vascular disease in relation to general risk factors, insulin level, and abnormalities in lipoprotein composition in non-insulin-dependent diabetic and nondiabetic subjects

The 5-year incidence of myocardial infarction and claudication was examined in a group of middle-aged patients (n = 133, 70 men and 63 women) with newly diagnosed non-insulin-dependent diabetes and nondiabetic control subjects (n = 144, 62 men and 82 women). The effects of general risk factors, plasma insulin level, and lipoprotein abnormalities on the incidence of myocardial infarction and claudication were also evaluated by univariate analyses in both diabetic patients and nondiabetic subjects and by multivariate analyses combining both groups. The age-adjusted incidence of myocardial infarction was higher both in diabetic men (19.4%) and diabetic women (11.0%) than in nondiabetic men (3.2%, p = 0.009) and nondiabetic women (3.0%, p = 0.047). Similarly, the age-adjusted incidence of claudication was higher among the diabetic patients (20.3% vs. 8.0% for men, p = 0.06; 21.8% vs. 4.2% for women, p = 0.003). None of the general risk factors (i.e., low density lipoprotein [LDL] cholesterol, blood pressure, smoking, and high density lipoprotein [HDL] cholesterol) showed an association with the risk of myocardial infarction either in the diabetic or nondiabetic groups of subjects, but an ischemic electrocardiographic abnormality at the baseline examination predicted myocardial infarction in diabetic men. In univariate analyses in diabetic subjects, high serum total cholesterol, low HDL cholesterol, high very low density lipoprotein (VLDL) cholesterol, and high total, LDL and VLDL triglycerides, and in nondiabetic subjects, high VLDL cholesterol and LDL triglycerides were associated with the appearance of claudication. In multivariate analyses including both diabetic and control subjects, only diabetes had an independent association with myocardial infarction, whereas smoking, high LDL triglycerides or VLDL cholesterol, and high fasting plasma insulin showed independent relations to claudication. The present results indicate that changes in lipoprotein composition characteristic of non-insulin-dependent diabetes are atherogenic and increase the risk of atherosclerotic vascular disease. Furthermore, high plasma insulin might also be involved in atherogenesis, independent of lipoprotein abnormalities.     

German origin clusters for high cardiovascular risk in an Italian enclave

Mortality and morbidity appear to be higher in a Cimbrian population representing an enclave of people who migrated from medieval Germany to the secluded Leogra valley in Italy. A population-based study was organized, recruiting 881 elderly subjects of Cimbrian origin and comparing them with a standard control population (SCP, n = 3,282) having comparable general characteristics and lifestyle. Serum lipids and glucose, blood pressure, heart rate, respiratory function, ECG abnormalities, and historical events were used as risk indicators. Age-adjusted systolic and pulse pressure were higher in the Cimbrians than in the SCP, while diastolic blood pressure was comparable. The prevalences of arterial hypertension, isolated systolic hypertension, and pulse hypertension were significantly more represented among Cimbrians than SCP. The prevalences of diabetes, hypercholesterolemia, and hypertriglyceridemia were higher among the former than the latter. The ratio between apolipoproteins B and A1 was also higher, while the HDL fraction was significantly lower in Cimbrians than in the SCP. In Cimbrians, the relative risk (RR) for ischemic heart disease was 1.92 (1.57-2.34) in women, 2.30 (1.54-3.43) in men and 1.03 (1.00-1.06) in women for stroke, 2.43 (1.54-3.83) in men and 1.45 (1.01-1.12) in women for atrial fibrillation, 3.85 (2.83-5.24) in men and 1.39 (1.20-1.60) in women for respiratory disease, 1.97 (1.32-2.94) in men and 6.81 (4.38-10.60) in women for intermittent claudication, and 3.31 (2.44-4.50) in men and 2.30 (1.76-3.01) in women for left ventricular hypertrophy. The subjects living in the secluded Leogra valley are at higher cardiovascular risk than the standard controls. Whether this depends on genetic factors, lifestyle, or both will need to be clarified by further analysis.     

Hypercholesterolemia. The evidence supports use of statins

Using statins to treat older men and women with coronary artery disease (CAD) and hypercholesterolemia reduces the risk of all-cause mortality, cardiovascular mortality, coronary events, coronary revascularization, stroke, Intermittent claudication, and congestive heart failure. The target serum low-density lipoprotein (LDL) cholesterol level is < 100 mg in older patients with CAD, prior stroke, peripheral arterial disease, extracranial carotid arterial disease, abdominal aortic aneurysm, diabetes meilitus, and the metabolic syndrome. Statins are also effective in reducing cardiovascular events in older persons with hypercholesterolemia without cardiovascular disease. Consider using statins in older persons without cardiovascular disease but with a serum LDL cholesterol > or = 130 mg/dL, or a serum high-density lipoprotein cholesterol < 50 mg/dL. Data from the Heart Protection Study favor treating patients at high risk for vascular events with statins regardless of age or initial serum lipids.     

The role of exercise training in peripheral arterial disease

Peripheral arterial disease (PAD) is currently a major health problem affecting 8-12 million Americans, 15-40% of whom will have intermittent claudication that can lead to substantial impairment in their ability to carry out normal daily activities as well as perform the recommended cardiovascular exercise. Supervised exercise training is an effective tool in the treatment of claudication and is currently a recommended first-line therapy for patients with this condition. In addition to improving pain-free walking distance and quality of life, supervised exercise training can improve many cardiovascular risk factors, possibly reducing the risk for subsequent myocardial infarction, stroke, and death. This paper will review the benefits of supervised exercise training in patients with PAD.     

Association between endothelial dysfunction and major cardiovascular events in peripheral arterial disease

BACKGROUND: Patients with peripheral arterial disease (PAD) are characterized by a high mortality for cardiovascular events. An impairment of endothelial function, expressed as brachial-artery flow-mediated vasodilation (FMV), has been described in PAD patients. Aim of this study was to investigate the association between FMV and cardiovascular events in patients with PAD. PATIENTS AND METHODS: Thirty-eight patients with intermittent claudication (71% men, mean age 71 years) were divided into two groups according to the presence or absence of previous major cardiovascular events (myocardial infarction or stroke). RESULTS: Brachial FMV was significantly lower in patients with a history of myocardial infarction or stroke (n = 16) than in patients without cardiovascular events (3.2 +/- 3.6% vs. 5.7 +/- 3.6%; p = 0.042). In the group with cardiovascular events there was a significantly higher proportion of subjects in the lower FMV tertile (56% vs. 18%), and a lower proportion of subjects in the upper tertile (25% vs. 41%; chi 2 test, p = 0.047). CONCLUSION: We conclude that FMV of the brachial artery is significantly reduced in PAD patients with a history of stroke and myocardial infarction. These cross-sectional results suggest a potential role of FMV as a marker of major cardiovascular events.     

Cigarette smoking and cardiovascular disease

Data on the impact of smoking on mortality indicate that 35% of smoking-related deaths are due to cardiovascular causes. Current cigarette smoking is associated with a threefold to sixfold increase in risk of myocardial infarction and increased rates of ischemic stroke and subarachnoid hemorrhage. Tobacco smoking has the greatest deleterious effect on peripheral arteries, with multiple effects ranging from increased peripheral arterial disease and associated intermittent claudication, limb ischemia, and graft failure to a threefold or more increase in abdominal aortic aneurysm formation. The recent recognition of secondhand smoke as a risk factor for cardiovascular disease has led to governmental action to develop smoke-free public environments. Small communities with public smoking bans have already seen reductions in cardiovascular mortality.     

Effect of aspirin on mortality in the primary prevention of cardiovascular disease

Objective

The lack of a mortality benefit of aspirin in prior meta-analyses of primary prevention trials of cardiovascular disease has contributed to uncertainty about the balance of benefits and risks of aspirin in primary prevention. We performed an updated meta-analysis of randomized controlled trials of aspirin to obtain best estimates of the effect of aspirin on mortality in primary prevention.

Methods

Eligible articles were identified by searches of electronic databases and reference lists. Outcomes of interest were all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, and bleeding. Data were pooled from individual trials using the DerSimonian-Laird random-effects model, and results are presented as relative risk (RR) and 95% confidence intervals (CIs).

Results

Nine randomized controlled trials enrolling 100,076 participants were included. Aspirin reduced all-cause mortality (RR 0.94; 95% CI, 0.88-1.00), myocardial infarction (RR 0.83; 95% CI, 0.69-1.00), ischemic stroke (RR 0.86; 95% CI, 0.75-0.98), and the composite of myocardial infarction, stroke, or cardiovascular death (RR 0.88; 95% CI, 0.83-0.94), but did not reduce cardiovascular mortality (RR 0.96; 95% CI, 0.84-1.09). Aspirin increased the risk of hemorrhagic stroke (RR 1.36; 95% CI, 1.01-1.82), major bleeding (RR 1.66; 95% CI, 1.41-1.95), and gastrointestinal bleeding (RR 1.37; 95% CI, 1.15-1.62). A lack of availability of patient-level data precluded exploration of benefits and risks of aspirin in key subgroups.

Conclusion

Aspirin prevents deaths, myocardial infarction, and ischemic stroke, and increases hemorrhagic stroke and major bleeding when used in the primary prevention of cardiovascular disease.     

Relationship between intermittent claudication, inflammation, thrombosis, and recurrent cardiac events among survivors of myocardial infarction

BACKGROUND: Among coronary disease patients, concomitant peripheral arterial disease is a potent risk factor for future cardiac events and mortality. We sought to determine clinical and biochemical markers that might better elucidate the relationship between coronary and peripheral arterial disease. METHODS: Two months after an index myocardial infarction, 1045 patients provided detailed medical histories and underwent blood testing for selected hemostatic, lipid, and inflammatory markers. Patients were then followed up prospectively for a mean of 26 months. RESULTS: Compared with individuals without intermittent claudication (n = 966), those with claudication (n = 78) (information was unavailable for 1 individual) were significantly older and demonstrated an increased frequency of diabetes mellitus, tobacco use, prior cardiac and cerebrovascular events, and depressed left ventricular function. Individuals with claudication were less likely to receive beta-blocker therapy after the index infarction. Individuals with claudication had evidence of enhanced procoagulant and proinflammatory states manifested by relative elevations in plasma fibrinogen, D-dimer, C-reactive protein, and serum amyloid A concentrations. During follow-up, the presence of claudication was associated with an independent 2-fold increase in the combined end point of death or nonfatal cardiac event (38.5% vs 17.8%, P =.001) and a 5-fold increase in cardiac mortality (19.2% vs 3.6%, P =.001). Patients with intermittent claudication who were not treated with beta-blockers had a significant 3-fold mortality excess relative to those receiving beta-blockers. CONCLUSIONS: Following myocardial infarction, the added presence of intermittent claudication is associated with heightened procoagulant and proinflammatory states and an underuse of beta-blocker therapy and is a strong independent predictor of recurrent cardiovascular events.     

Intermittent claudication: From its risk factors to its long-term prognosis in men. The Quebec Cardiovascular Study

BACKGROUND:

The natural history of intermittent claudication, from its risk factors to its cardiovascular prognosis, has been reported in few prospective studies.

OBJECTIVE:

To assess incident intermittent claudication, as well as its risk factors and long-term prognosis in men.

METHODS:

A random sample of 4376 men 35 to 64 years of age from Quebec City (Quebec), who were free of cardiovascular disease (CVD), was evaluated in 1974 for CVD risk factors and followed until 1998. To assess the prognosis, the event rates between 1985 and 1998 were computed among men with incident claudication without other CVD, incident survivors of a first myocardial infarction (MI) without other CVD and men free of CVD between 1974 and 1985.

RESULTS:

From 1974 to 1998, 300 men developed intermittent claudication. Tobacco consumption, high systolic blood pressure and diabetes at least doubled the adjusted RR (aRR) of intermittent claudication. In 1985, there were 80 claudicants, 2868 men free of CVD and 68 survivors of a first MI. During the 13-year follow-up, a new CVD occurred in 48.8% of the claudicants, in 18.9% of men without CVD (aRR 2.08; 95% CI 1.48 to 2.90) and in 45.6% of MI survivors (aRR compared with claudicants 1.12; 95% CI 0.69 to 1.79). There was also no significant difference between claudicants and MI survivors for fatal CVD, nonfatal CVD and total mortality.

CONCLUSIONS:

Men with intermittent claudication are at high risk for CVD that may be equivalent to men with previous MI.     

Ischemic stroke in patients with intermittent claudication: a clinical study of 142 cases

The clinical features, risk factors, neuroimaging findings, and outcome of acute ischemic stroke were assessed in patients with intermittent claudication. Data from 142 patients with ischemic stroke and intermittent claudication were collected from a prospective hospital-based stroke registry in which 2500 consecutive acute stroke patients attended over a 12-year period. Ischemic stroke in patients with intermittent claudication accounted for 7.7% of all ischemic strokes (n = 1840). Ischemic stroke with and without intermittent claudication showed a similar in-hospital mortality rate (16% vs 14%) and absence of functional limitation at hospital discharge (20.5% vs 18.5%). Ischemic stroke patients with intermittent claudication showed a significantly shorter length of stay than patients without symptomatic peripheral arterial disease (14.6 vs 18.8 days, p < 0.05). Ischemic heart disease, transient ischemic attack (TIA), renal dysfunction, and watershed infarct were significant independent predictors of ischemic stroke in patients with intermittent claudication. Although cerebral infarction in patients with intermittent claudication showed a clinical profile suggestive of poor outcome, the prognosis was similar to that of ischemic stroke without intermittent claudication.     

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

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

Peripheral Arterial Disease and Its Relationship to Cardiovascular Risk Factors and Coronary Heart Disease in Newly Diagnosed Non-insulin-dependent Diabetics

ABSTRACT The prevalence of peripheral arterial disease and its relationship to cardiovascular risk factors was investigated in 133 patients aged 45–64 years with newly diagnosed non-insulin-dependent diabetes and in 144 randomly selected non-diabetic subjects of the same age. History of intermittent claudication, absent foot pulses, decreased ankle-arm blood pressure ratio (<0.9) and radiologically detectable arterial calcifications of the lower limbs were used as indicators of the presence of peripheral arterial disease. Peripheral arterial disease tended to be somewhat more common in men with newly diagnosed non-insulin-dependent diabetes than in non-diabetic men, whereas no difference was found in prevalence of peripheral arterial disease between diabetic and non-diabetic women. The association of various indicators of peripheral arterial disease with cardiovascular risk factors and coronary heart disease was low or absent.     

Lipoprotein(a) further increases the risk of coronary events in men with high global cardiovascular risk

OBJECTIVES: This prospective population study was conducted to assess the role of elevated lipoprotein(a) [Lp(a)] as a coronary risk factor. BACKGROUND: The role of elevated Lp(a) as a risk factor for coronary heart disease is controversial. In addition, little attention has been paid to the interaction of Lp(a) with other risk factors. METHODS: A total of 788 male participants of the Prospective Cardiovascular Münster (PROCAM) study aged 35 to 65 years were followed for 10 years. Both Lp(a) and traditional cardiovascular risk factors (e.g., age, low density lipoprotein [LDL] cholesterol, high density lipoprotein [HDL] cholesterol, triglycerides, systolic blood pressure, cigarette smoking, diabetes mellitus, angina pectoris, and family history of myocardial infarction) were evaluated in 44 men who suffered from myocardial infarction, and in 744 men who survived without major coronary events or stroke. A multiple logistic function algorithm was used to estimate global cardiovascular risk by the combined effects of traditional risk factors. RESULTS: Overall, the risk of a coronary event in men with an Lp(a) > or =0.2 g/liter was 2.7 times that of men with lower levels (95% confidence interval [CI]: 1.4 to 5.2). This increase in risk was most prominent in men with LDL cholesterol level > or =4.1 mmol/liter (relative risk [RR]: 2.6; 95% CI: 1.2 to 5.7), with HDL cholesterol < or =0.9 mmol/liter (RR 8.3; 95% CI: 2.0 to 35.5), with hypertension (RR 3.2; 95% CI: 1.4 to 7.2), or within the two highest global risk quintiles (relative risk: 2.7; 95% CI: 1.3 to 5.7). CONCLUSIONS: Lp(a) increases the coronary risk, especially in men with high LDL cholesterol, low HDL cholesterol, hypertension and/or high global cardiovascular risk.     

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

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