Coronary Heart Disease In Population Research Articles

Association of Interleukin-1 gene polymorphisms with central obesity and metabolic syndrome in a coronary heart disease population

The objective of this study was to determine whether single nucleotide polymorphisms (SNPs) in the Interleukin-1 (IL-1) gene family are associated with central obesity and metabolic syndrome in a coronary heart disease population. The IL-1 alpha C-889T (rs1800587) and IL-1 beta +3954 (rs1143634) SNPs were studied in a Western Australian coronary heart disease (CHD) population (N = 556). Subjects who were TT homozygous at either SNP had larger waist circumference (IL-1 alpha: 1.8 cm greater, P = 0.04; IL-1 beta: 4 cm greater, P = 0.0004) compared with major allele homozygotes. Individuals with two copies of the IL-1 alpha:IL-1 beta T:T haplotype had greater waist circumference (4.7 cm greater, P = 0.0001) compared to other haplotypes. There was a significant interaction between the IL-1 beta SNP and BMI level on waist circumference (P = 0.01). When the cohort was stratified by median BMI, TT carriers for IL-1 beta with above median BMI had greater waist circumference (6.1 cm greater, P = 0.007) compared to baseline carriers, whilst no significant association was seen in the below median group. Similarly, when the cohort was stratified by median fibrinogen level (IL-1 alpha interaction P = 0.01; IL-1 beta interaction P = 0.04), TT carriers for both SNPs in the above median fibrinogen group had greater waist circumference (IL-1 alpha 2.7 cm greater, P = 0.007; IL-1 beta 3.3 cm greater, P = 0.003) compared with major allele homozygotes. This association was not seen in the below median group. Also, we found a trend of increased metabolic syndrome for IL-1 beta TT homozygotes (P = 0.07). In conclusion, our findings suggest that in a CHD population IL-1 gene polymorphisms may be involved in increased central obesity, and the genetic influences are more evident among patients who have a higher level of obesity or inflammatory markers.

Patient-reported health status in coronary heart disease in the United States: age, sex, racial, and ethnic differences.

Coronary heart disease (CHD) affects 15.8 million Americans. However, data on the national impact of CHD on health-related quality of life, particularly among people of different age, sex, racial, and ethnic groups, are limited. Using data from the 2000 and 2002 Medical Expenditure Panel Survey, we examined various measures of patient-reported health status, including health-related quality of life, in the CHD and non-CHD populations and differences in the measures among demographic subgroups. These measures included short-form generic measures (Short Form 12; Mental Component Summary-12 and Physical Component Summary-12) and EuroQol Group measures (EQ-5D index and EQ visual analog scale). Ordinary least-squares regressions were used to adjust for sociodemographic characteristics, risk factors, comorbidities, and proxy report. The adjusted difference between the CHD and non-CHD populations was -1.2 for Mental Component Summary-12 (2.4% of the score in the non-CHD population), -4.6 for Physical Component Summary-12 (9.2%), -0.04 for EQ-5D (4.6%), and -7.3 for EQ visual analog scale (9.0%) (all P<0.05). Differences among demographic subgroups were observed. Particularly, compared with whites, the differences between CHD and non-CHD in blacks were bigger in all measures except Physical Component Summary-12. A significantly bigger difference in Mental Component Summary-12 also was observed among Hispanics compared with non-Hispanics. CHD is associated with significant impairment of health-related quality of life and other patient-reported health status in the US adult population. Differences in the impairment associated with CHD exist across different age, racial, and ethnic groups. In addition to preventing CHD, effective public health interventions should be aimed at improving health-related quality of life and perceived health status in the CHD population, especially the most vulnerable groups.

Factor structure of the Hospital Anxiety and Depression Scale in coronary heart disease patients in three countries

Depression and anxiety in patients with coronary heart disease (CHD) is associated with a poorer prognosis. Therefore, the screening for psychological distress is strongly recommended in cardiac care and rehabilitation. The Hospital Anxiety and Depression Scale (HADS) is a widely used screening tool that has demonstrated good sensitivity and specificity for mental disorders. The factor structure of the HADS was investigated in CHD populations across three countries (Germany, Hong Kong, United Kingdom). In total, HADS data from 1793 patients with CHD were explored using confirmatory factor analysis to establish the underlying factor structure of the instrument. Three-factor models were found to offer a superior fit to the data compared with two-factor (anxiety and depression) models in all countries. The anxiety items can be separated in a factor labelled autonomic anxiety and negative affectivity. The HADS offers good possibilities to detect distressed patients with somatic illnesses, but the construct validity of the originally proposed two factors (depression, anxiety) remains unclear. In outcome studies, more precise scales should be used to reduce measurement errors based on the scales used.

Antidepressants in Coronary Heart Disease

IN THIS ISSUE OF JAMA, LESPERANCE ET AL 1 REPORT THE results of the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial, a blinded, randomized controlled clinical trial testing the efficacy of the selective serotonin reuptake inhibitor (SSRI) citalopram and interpersonal psychotherapy in 284 patients with major depressive disorder. The efficacy of citalopram and interpersonal psychotherapy in the treatment of major depression in patients primarily free of coronary heart disease (CHD) is well documented. The clinical importance of CREATE is that it involved patients with comorbid CHD. Depression is a painful, functionally impairing, and frequently recurrent condition that in patients with either coronary or cerebral vascular disease also significantly increases the risk of cardiovascular morbidity and mortality. A recent report found 17 studies indicating that depression following a coronary event was associated with a 3-fold increase in cardiac mortality. Despite the ominous implications of depression occurring in patients with CHD, there is limited information to guide its treatment and questions have even been raised about whether treatment is needed. Some physicians consider major depressive disorder that is detected after an acute coronary syndrome (ACS) episode as an understandable reaction to stress that will remit when the coronary condition stabilizes. However, recent studies show that most major depressive disorders observed after ACS began long before the coronary event, which therefore could not have provoked the depression. In 1993, Frasure-Smith et al first raised the question of whether treating depression after ACS would reduce cardiac morbidity and mortality. At that time, neither safety nor efficacy data were available for any antidepressant during the post-ACS period. The Sertraline Antidepressant Heart Attack Randomized Trial (SADHART) tested the safety and antidepressant efficacy of sertraline in patients with ACS as a step to test mortality reduction. SADHART found no adverse cardiovascular effects associated with sertraline treatment and reported that depressive symptoms improved in patients whose depression was severe or began before the coronary event or those who had a history of prior episodes. Among patients whose depressive episode was mild or first began after their coronary event, placebo response rates were high with no significant drug-placebo difference. SADHART, with 369 patients, was not powered to determine whether sertraline reduced death or recurrent myocardial infarction (MI). The Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial, which randomized 1834 depressed, post-MI patients, was adequately powered to test whether cognitive behavioral therapy would reduce death compared with usual care. Treatment with cognitive behavioral therapy reduced depression modestly but not death or recurrent MI. For ethical reasons, patients enrolling with more severe depression or failing to respond to cognitive behavioral therapy were offered an antidepressant drug. Approximately 20% received an SSRI, usually sertraline. Patients treated with an SSRI, whether assigned to receive cognitive behavioral therapy or usual care, had a 42% reduction in death or recurrent MI compared with the 1388 depressed patients not receiving an antidepressant. Although not based on randomized treatment, this difference was highly statistically significant. The CREATE trial documents the antidepressant efficacy of a second SSRI, citalopram, in a comorbid CHD population. Although CREATE, ENRICHD, and SADHART all enrolled patients meeting criteria for major depressive disorder, half the participants in ENRICHD and SADHART had less severe depression than that required for enrollment in CREATE. The majority of patients participating in SADHART and ENRICHD began treatment in the first month after experiencing ACS when risk of cardiovascular events is high. In contrast, patients in the CREATE trial began treatment on average more than 18 months after their index event. Despite these differences, SADHART and CREATE found similar drug-response characteristics. CREATE limited enrollment to patients with moderate to severe depression and found citalopram had a response rate of 31% greater than

Does Sex Matter in the Associations between Classic Risk Factors and Fatal Coronary Heart Disease in Populations from the Asia-Pacific Region?

There is much interest in promoting healthy heart awareness among women. However, little is known about the reasons behind the lower rates of heart disease among women compared with men, and why this risk difference diminishes with age. Previous comparative studies have generally had insufficient numbers of women to quantify such differences reliably. We carried out an individual participant data meta-analysis of 39 cohort studies (32 from Asian countries and 7 from Australia and New Zealand). Cox models were used to estimate hazard ratios (HR) for coronary death, comparing men to women. Further adjustments were made for several proven coronary risk factors to quantify their contributions to the sex differential. Sex interactions were tested for the same risk factors. During 4 million person-years of follow-up, there were 1989 (926 female) deaths from coronary heart disease (CHD). The age-adjusted and study-adjusted male/female HR (95% confidence interval [95% CI]) was 2.05 (1.89-2.22). At baseline, 54% of men vs. 7% of women were current smokers; hence, adjustment for smoking explained the largest component (20%) of this HR. A significant sex interaction was observed between systolic blood pressure (SBP) and CHD mortality such that a 10 mm Hg increase was associated with a 15% greater increase in the relative risk (RR) of coronary death in women compared with men (p = 0.002). Only a small amount of the sex differential in coronary death could be explained by differences in the prevalence of classic risk factors. Alternative explanations are required to explain the age-related attenuation of the sex difference in CHD risk.

Metabolic issues and cardiovascular disease in patients with psychiatric disorders

Individuals with psychiatric disorders tend to have excessive morbidity. They typically have high rates of respiratory illnesses, infectious diseases, substance abuse (including smoking), obesity, diabetes mellitus, and cardiovascular disease (CVD). Persons with schizophrenia and affective disorders also have a high prevalence of risk factors for CVD, such as diabetes and obesity, which are on the order of 1.5 to 2.0 times higher than in the general population; this translates into increased mortality rates due to CVD. The use of certain psychotropics results in metabolic sequelae, such as obesity, dyslipidemia, glucose dysregulation, and the metabolic syndrome. These sequelae exacerbate the already elevated risk of CVD and diabetes in this group of people. Therefore, the use of psychotropic agents that result in, for example, excessive weight gain not only add another complication for physicians managing a patient with schizophrenia but also may have serious prognostic and cost implications with respect to treatment-related diabetes and coronary disease incidence. The recent American Diabetes Association (ADA) Consensus Panel concluded that some agents are associated with greater diabetes risk than others. The current review describes the prevalence of the metabolic syndrome in people with affective disorders and schizophrenic populations, its prognostic relevance, and its exacerbation among patients treated with particular psychotropic agents, including certain atypical antipsychotics, selective serotonin reuptake inhibitors, and mood stabilizers. The costs associated with the treatment of the metabolic syndrome, diabetes, and coronary heart disease in populations with schizophrenia are also described.

Efficacy and safety of simvastatin in Asian and non-Asian coronary heart disease patients: a comparison of the GOALLS and STATT studies

SUMMARYBackground: Asians are thought to be more responsive to the lipid-lowering effects of statins than non-Asians although there are no head-to-head trials that examine this perception.Objective: To compare the results of the GOALLS and STATT studies that used similar titrate-to-goal protocols with 20 mg up to 80 mg simvastatin in Asian and non-Asian coronary heart disease (CHD) patients.Methods: GOALLS (N = 198; included non-Asians and Asians) and STATT (N = 133; included Asians only) were both multi-center, open-label 14-week studies in CHD patients with serum low density lipoprotein cholesterol (LDL-C) levels 115 mg/dL–180 mg/dL and triglycerides (TG) levels ≤ 400 mg/dL. Simvastatin was titrated from 20 mg/day up to 80 mg/day in order to achieve the National Cholesterol Education Program (NCEP) LDL-C target ≤ 100 mg/dL. The primary efficacy variable was the percentage of patients attaining the NCEP LDL-C target at Week 14. Secondary endpoints included proportion of patients achieving the European Society of Cardiology/European Atherosclerosis Society/European Society of Hypertension (European) LDL-C target ≤ 115 mg/dL at Week 14 and percentage change in lipid parameters. Safety and tolerability were assessed by monitoring adverse experiences and safety laboratory tests. Fifteen Asian patients were part of the GOALLS cohort and their data were compared separately with results of non-Asians from GOALLS and Asians from the STATT study.Results: After 14 weeks of simvastatin treatment, 87.1% of GOALLS non-Asians, 85.7% of GOALLS Asians, and 78.2% of STATT patients attained the NCEP LDL-C target. At Week 14, 94.4%, 92.9%, and 91.7% of the GOALLS non-Asians, GOALLS Asians, and STATT patients achieved the European LDL-C target, respectively. The average treatment doses to attain NCEP and European targets were comparable among groups. The percentage reductions in lipid parameters from baseline to week 14 were similar among groups except, changes in high density lipoprotein cholesterol and apolipoprotein A-I favored Asian subjects. There was also a greater reduction in TG in the STATT study, but this was not consistent with TG reductions experienced by Asians in the GOALLS study. In both studies, simvastatin was generally well tolerated by all patients across the dosage range of 20 mg–80 mg. No cases of rhabdomyolysis or myopathy were reported in either study.Conclusions: A great majority of CHD patients is able to achieve LDL-C treatment goals (up to 90%) on simvastatin regardless of racial background. Simvastatin treatment at doses of 20 mg–80 mg is well-tolerated in Asian and non-Asian CHD patients. This side-by-side comparison provides evidence that Asian and non-Asian CHD populations respond similarly to comparable doses of simvastatin.

Improving Treatment Regimen Adherence in Coronary Heart Disease by Targeting Patient Types

Patient adherence to a treatment plan is central to the control of coronary heart disease (CHD) and in the prevention of complications; it is reported to be the single most important challenge in the management of CHD and related conditions. The following article provides an overview of adherence in CHD, with particular emphasis on two important theories of behavior change: the ‘Health Belief Model’ and the ‘Transtheoretical Model’. Three types of individuals are discussed in relation to these theories: (i) patients who are non-adherent (5–10% of the CHD population); (ii) patients who are partially adherent (30–40% of the CHD population); and (iii) patients who are near-optimally adherent (50–60% of the CHD population). Adherence predictor strategies and recommended interventions for each of these groups are provided in table format. Disease management tools and resources that assist in targeting interventions to the unique adherence needs of these three very different groups are also listed. It was our conclusion that regardless of the interventions that are utilized in CHD management programs, understanding the differences between partially adherent, non-adherent, and near-optimally adherent patients, and targeting interventions to these groups, can optimize the impact of CHD interventions.

The emergence of coronary heart disease in populations of Chinese descent

Most countries in oriental Asia have not yet experienced the ‘western’ coronary heart disease (CHD) epidemic despite substantial economic development. An exception has been Singapore. We compared mortality and CHD risk factors in Singapore with two Oriental locations, Hong Kong and mainland China, which have not experienced the CHD epidemic. Mortality data from World Health Statistics Annuals age standardised for each location and were supplemented by local data. Risk factor data was obtained from population-based surveys using similar protocols in each location. Measures included diet, blood lipids, blood pressure, height and weight. CHD mortality in the year chosen for comparison, 1994, was significantly higher for Singapore Chinese males [108 (95.2–119.1)] than Chinese males in Hong Kong [44.3 (40.2–48.2)] or China [45.5 (44.2–46.8)]. Female CHD mortality was also relatively higher in Singapore Chinese. The only CHD risk factor markedly higher in Singapore Chinese was serum cholesterol; Singapore males [5.65 (5.55–5.75)], females [5.60 (5.50–5.70)], Hong Kong males [5.21 (5.11–5.31)], females [5.20 (5.10–5.29)] and China males [4.54 (4.46–4.62)], females [4.49 (4.42–4.55)]. Dietary differences in saturated fat consumption were consistent with this. Although there was little difference in total fat intake, a higher consumption of dietary saturated fat and lower consumption of polyunsaturated fat, accompanied by higher serum cholesterol, appear to explain the relatively high CHD mortality in Singapore compared with Hong Kong and mainland China. Differences in body mass index, blood pressure and smoking between locations did not explain the differences in CHD mortality.

Prevalencia del síndrome metabólico entre pacientes con cardiopatía isquémica

We aimed to know the prevalence of classical cardiovascular risk factors, hyperinsulinism, insulin resistance and metabolic syndrome (MS) in a population with coronary heart disease (CHD) as compared with a population without personal or familial history of cardiovascular risk factors. This was an observational and transversal study of cardiovascular risk factors making up the MS in an adult population. 367 subjects aged 35-79 years (268 men and 99 women) were studied; 185 had CHD (141 men and 44 women) and 182 (127 men and 55 women) were included as a control population. 82 individuals of the control group who had no MS components were selected for the calculation of parameters of hyperinsulinism and the HOMA (Homeostasis Model Assessment) index in order to evaluate the insulin resistance. As compared with the control group, patients with CHD showed higher blood pressure (systolic and dyastolic), body mass index (BMI), triglicerydes and apo B100 concentrations, and lower HDL-c and apo A1 values. They also exhibited higher values of glycemia and insulinemia and consequently a higher HOMA index. The values of insulin and HOMA (percentil 75), obtained from the selected group for this purpose, were 12 U/ml and 3.03, respectively. In the CHD population, 38.28% (95% CI, 31.13-45.95) had hyperinsulinism, 47.02% (95% CI, 39.70-54.47) had insulin resistance (HOMA) and 41.08% (95% CI, 33.98-48.55) had MS. There was a high prevalence of cardiovascular risk factors in the CHD population. Patients with CHD have higher hyperinsulinism and insulin resistance as well as a greater prevalence of MS. Despite treatment, a clear association exists between MS and CHD in both men and women.

Impact of Smoking Reduction on Coronary Heart Disease Mortality Trends During 1981–2000 in England and Wales

ObjectiveTo explore how much of the coronary heart disease (CHD) mortality fall in England and Wales can be attributed to changes in smoking prevalence.MethodsA previously validated cell-based IMPACT CHD mortality model was used to estimate the deaths prevented or postponed by changes in population smoking prevalence in England and Wales between 1981 and 2000. CHD mortality statistics and population trends in smoking were obtained from routine data sources.ResultsIn England and Wales between 1981 and 2000, smoking prevalence in adults aged 25–84 decreased from 43% to 28% in men and from 35% to 24% in women. In men, most of the decrease occurred in those aged over 55. Smoking prevalence changed little in older women. An estimated 29,460 deaths were prevented or postponed (DPP) by this population reduction in smoking prevalence. Most of this benefit was seen in men (86% of the DPPs versus 14% in women).ConclusionLarge declines in smoking prevalence accounted for 29,460 fewer CHD deaths in England and Wales in 2000 compared with 1981. This emphasises the importance of a national strategy with comprehensive tobacco control programmes to further reduce smoking.

Impact of Smoking Reduction on Coronary Heart Disease Mortality Trends During 1981–2000 in England and Wales

ObjectiveTo explore how much of the coronary heart disease (CHD) mortality fall in England and Wales can be attributed to changes in smoking prevalence.MethodsA previously validated cell-based IMPACT CHD mortality model was used to estimate the deaths prevented or postponed by changes in population smoking prevalence in England and Wales between 1981 and 2000. CHD mortality statistics and population trends in smoking were obtained from routine data sources.ResultsIn England and Wales between 1981 and 2000, smoking prevalence in adults aged 25–84 decreased from 43% to 28% in men and from 35% to 24% in women. In men, most of the decrease occurred in those aged over 55. Smoking prevalence changed little in older women. An estimated 29,460 deaths were prevented or postponed (DPP) by this population reduction in smoking prevalence. Most of this benefit was seen in men (86% of the DPPs versus 14% in women).ConclusionLarge declines in smoking prevalence accounted for 29,460 fewer CHD deaths in England and Wales in 2000 compared with 1981. This emphasises the importance of a national strategy with comprehensive tobacco control programmes to further reduce smoking.

Lipid-Lowering Medication for Secondary Prevention of Coronary Heart Disease in a German Outpatient Population: The Gap Between Treatment Guidelines and Real Life Treatment Patterns

Background. Few published data in particular from the United States indicate that the implementation of guidelines for prevention of coronary heart disease (CHD) is far from optimal. The objective of our study was to identify the type and prevalence of lipid-lowering medications in a German outpatient CHD population and to examine the impact of applied treatment regimens on serum lipid levels.Methods. Retrospective analysis of the washout phase of 2,856 CHD patients requiring lipid-lowering medication. Data are derived from a multicenter, randomized, open-label, parallel group clinical trial comparing the safety and efficacy of atorvastatin versus simvastatin in 591 centers in Germany. Medical history, physical examination, and serum lipid levels were obtained at the beginning of the washout phase (Week −6) and at the end of the washout phase (Week −1, i.e., 5 weeks after the discontinuation of all prior lipid-lowering medications). The data at Week −6 represented the lipid levels under real life conditions. The difference from the data at Week −1 reflected the therapeutic effects achieved by the previous lipid-lowering treatment.Results. The mean low-density lipoprotein cholesterol (LDL-C) level at Week −6 was 173.4 ± 42.5 mg/dl. Only 176 (6.2%) of 2,856 CHD patients were found to meet the target LDL-C level of <115 mg/dl at Week −6, only 76 (2.7%) patients had LDL-C levels <100 mg/dl, and 363 (12.7%) patients had LDL-C levels <130 mg/dl. After discontinuation of all prior lipid-lowering medications, mean LDL-C increased to 187.2 ± 44.0 mg. This means that only a marginal 7.4% reduction in LDL-C level was achieved under real life treatment conditions. This limited LDL-C reduction was due mainly to the low prevalence of lipid-lowering treatment (65.5% of patients did not receive any medication at all) and inadequate dosing. With respect to the effect on LDL-C and total cholesterol, statins alone were superior to fibrates.Conclusion. The study shows that there is a wide gap between treatment guidelines and real life treatment patterns in Germany. Awareness of the risks of high cholesterol levels has to be increased among both patients and physicians. Available treatment guidelines should be better implemented.

Frequency of serum low-density lipoprotein cholesterol measurement and frequency of results ≤100 mg/dl among patients who had coronary events (Northwest VA Network Study)

This population-based, cross-sectional analysis targeted all veterans with coronary heart disease (CHD) who were active patients in primary care or cardiology clinics in the Veterans Health Administration Northwest Network from July 1998 to June 1999. We report guideline compliance rates, including whether low-density lipoprotein (LDL) was measured, and if measured, whether the LDL was ≤100 mg/dl. In addition, we utilized multivariate logistic regression to determine patient characteristics associated with LDL measurements and levels. Of 13,891 active patients with CHD, 5,552 (40.0%) did not have a current LDL measurement. Of those with LDL measurements, 39.1% were at the LDL goal of ≤100 mg/dl, whereas 26.5% had LDL ≥130 mg/dl. Male gender, younger age, history of angioplasty or coronary artery bypass grafting, current hypertension, diabetes mellitus, and angina pectoris were associated with increased likelihood of LDL measurement. Older age and current diabetes and angina were associated with increased likelihood of LDL being ≤100 mg/dl, if measured. Although these rates of guideline adherence in the CHD population compare well to previously published results, they continue to be unacceptably low for optimal clinical outcomes. Attention to both LDL measurement and treatment (if elevated) is warranted.

Risk Factors for Coronary Heart Disease in a Population with a High Prevalence of Obesity and Diabetes: A Case-Control Study of the Polynesian Population of Western Samoa

Objective To evaluate anthropometric, haemodynamic and biochemical risk markers for coronary heart disease (CHD) in the Polynesian population of Western Samoa in a case-control study of 43 cases of CHD compared with 90 age- (mean 53 years) and sex-matched controls. Methods Cases were identified on the basis of a 12-lead electrocardiogram and clinical history. Results More than 60% of the participants had a body mass index ≥ 30 kg/m2 and nearly 80% had central obesity. Both diabetes mellitus (17%) and impaired glucose tolerance (9%) were also common in this population. Nineteen per cent of the population were hypertensive and both antihypertensive therapy (21 versus 1%, P<0.001, risk 23.6) and hypertension (35 versus 11%, P<0.01, risk 4.3) were significantly more common among cases than they were among controls. In addition, the plasma high-density lipoprotein cholesterol level was lower (1.00±0.09 versus 1.24±0.05 mmol/l, P<0.05) and the plasma urate level was higher (0.42±0.02 versus 0.37±0.01 mmol/l, P<0.05) in the female cases than they were in their respective controls. Low-density lipoprotein (LDL) particle sizing did not reveal an excess of small LDL particles to be a feature of CHD cases, but more than 70% both of cases and of controls had multiple LDL species. The response of the triglyceride level to a fat-rich meal was the same for CHD cases and controls. Conclusion The population studied had a high prevalence of several risk factors for CHD, including obesity and non-insulin-dependent diabetes mellitus; however, the most prominent factor relating to CHD within the community was the presence of hypertension.

Risk factors for coronary heart disease in a population with a high prevalence of obesity and diabetes: a case-control study of the Polynesian population of Western Samoa

To evaluate anthropometric, haemodynamic and biochemical risk markers for coronary heart disease (CHD) in the Polynesian population of Western Samoa in a case-control study of 43 cases of CHD compared with 90 age- (mean 53 years) and sex-matched controls. Cases were identified on the basis of a 12-lead electrocardiogram and clinical history. More than 60% of the participants had a body mass index > or =30 kg/m2 and nearly 80% had central obesity. Both diabetes mellitus (17%) and impaired glucose tolerance (9%) were also common in this population. Nineteen per cent of the population were hypertensive and both antihypertensive therapy (21 versus 1%, P<0.001, risk 23.6) and hypertension (35 versus 11%, P<0.01, risk 4.3) were significantly more common among cases than they were among controls. In addition, the plasma high-density lipoprotein cholesterol level was lower (1.00+/-0.09 versus 1.24+/-0.05 mmol/l, P<0.05) and the plasma urate level was higher (0.42+/-0.02 versus 0.37+/-0.01 mmol/l, P<0.05) in the female cases than they were in their respective controls. Low-density lipoprotein (LDL) particle sizing did not reveal an excess of small LDL particles to be a feature of CHD cases, but more than 70% both of cases and of controls had multiple LDL species. The response of the triglyceride level to a fat-rich meal was the same for CHD cases and controls. The population studied had a high prevalence of several risk factors for CHD, including obesity and non-insulin-dependent diabetes mellitus; however, the most prominent factor relating to CHD within the community was the presence of hypertension.

Relative risk of factors for coronary heart disease in population with low cholesterol levels

We studied the odds ratios of seven leading risk variables in a population essentially having a ‘low’ cholesterol concentration. In a cross-sectional population-based study of 3689 Turkish adults 20 years of age or over, 90 men and 83 women were diagnosed to have definite or suspected coronary heart disease. The criteria were based on history, cardiovascular examination and on Minnesota coding of electrocardiograms. Potential risk factors studied were: plasma total cholesterol (≥ 240 mg/dl), fasting triglycerides (≥ 200 mg/dl), diabetes mellitus, hypertension (asystolic ≥ 160 mmHg, diastolic ≥ 95 mmHg, or both, or subjects reporting to take antihypertensive medication), smoking currently or in the past, obesity (body mass index ≥ 30 kg/m 2), and physical inactivity. Hypertension and lack of physical exercise constituted the most important risk factors in both sexes being valid for all age groups and having high attributable risks; odds ratios in men and women, respectively, were 3.16 and 2.6 for hypertension, and 2.16 and 3.49 for physical inactivity. Hypertriglyceridemia followed these factors in men with an odds ratio of 2.15. In women an additional significant factor was obesity (odds ratio 1.76), while diabetes and hypercholesterolemia revealed to be significant only in those aged 20–59 years, and smoking in women aged 30–59 years. Among men, smoking was a borderline significant risk factor for coronary disease, whereas hypercholesterolemia did not prove to be so. These findings, somewhat at variance with those of industrialized nations, may have significance for policy of cardiovascular disease prevention in third-world populations.

Recent advances in clinical research involving carotenoids

Abstract

Relationship between stature and coronary heart disease in a German male population

Short stature in men has previously been associated with a higher risk of coronary heart disease. In order to further investigate this observation, the physical characteristics of 4470 German men admitted to the Klinik Roderbirken between 1978 and 1989 with a documented myocardial infarction and with a stenosis ≥ 75% in at least one vessel were compared to those of 711 male controls. Results indicated that the myocardial infarct group was significantly shorter by 1.8 cm than the control group ( p < 0.001). However, discriminant function analysis indicated that height accounted for only 1% of the variance between the cardiac and control patients. Classification analysis further indicated that on the basis of height, the percentage of subjects correctly classified for grouping was no better than 54% for the myocardial infarct patients and 57% for the controls. It was concluded that height exerted a minimal influence on coronary heart disease in this population.

Serum cholesterol concentration and coronary heart disease in population with low cholesterol concentrations.

To examine the relation between serum cholesterol concentration and mortality (from coronary heart disease and from other causes) below the range of cholesterol values generally seen in Western populations. Prospective observational study based on 8-13 years of follow up of subjects in a population with low cholesterol concentrations. Urban Shanghai, China. 9021 Chinese men and women aged 35-64 at baseline. Death from coronary heart disease and other causes. The average serum cholesterol concentration was 4.2 mmol/l at baseline examination, and only 43 (7%) of the deaths that occurred during 8-13 years of follow up were attributed to coronary heart disease. There was a strongly positive, and apparently independent, relation between serum cholesterol concentration and death from coronary heart disease (z = 3.47, p less than 0.001), and within the range of usual serum cholesterol concentration studied (3.8-4.7 mmol/l) there was no evidence of any threshold. After appropriate adjustment for the regression dilution bias, a 4 (SD 1)% difference in usual cholesterol concentration was associated with a 21 (SD 6)% (95% confidence interval 9% to 35%) difference in mortality from coronary heart disease. There was no significant relation between serum cholesterol concentration and death from stroke or all types of cancer. The 79 deaths due to liver cancer or other chronic liver disease were inversely related to cholesterol concentration at baseline. Blood cholesterol concentration was directly related to mortality from coronary heart disease even in those with what was, by Western standards, a "low" cholesterol concentration. There was no good evidence of an adverse effect of cholesterol on other causes of death.