Determinants Of Cardiovascular Disease Research Articles

Long-term survival and causes of death after stroke.

As part of the Danish contribution to the World Health Organization (WHO) MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) Project, a register of patients with stroke was established in 1982. The purpose of the present study was to analyze long-term survival and causes of death after a first stroke and to compare them with those of the background population. The study population comprised all subjects aged 25 years or older who were resident in a geographically defined region in Copenhagen County. All stroke events in the study population during 1982-1991 were ascertained and validated according to standardized criteria outlined for the WHO MONICA Project. After completion of the stroke registry at the end of 1991, all patients were followed up by record linkage to official registries. Standardized mortality ratios were calculated for various causes of death and periods after the stroke. The estimated cumulative risks for death at 28 days, 1 year, and 5 years after onset were 28%, 41%, and 60%, respectively. Compared with the general population, nonfatal stroke was associated with an almost 5-fold increase in risk for death between 4 weeks and 1 year after a first stroke and a 2-fold increase in the risk for death subsequent to 1 year. The excess mortality rate in stroke patients was due mainly to cardiovascular diseases but also to cancer, other diseases, accidents, and suicide. The probability for long-term survival improved significantly during the observation period for patients with ischemic or ill-defined stroke. Stroke is a medical emergency associated with a very high risk for death in the acute and subacute phases and with a continuous excess risk of death. Better prevention and management of strokes may improve the long-term survival rate.

IBALD-MULLI AND PETERS RESPOND

We welcome the comments from Linn and Gong and are very pleased that they found effects of ambient particulate pollution on blood pressure similar to those found by us and our colleagues.1 Although the 2 studies differ in their design, they both assessed short-term effects of particulate air pollution on the basis of 24-hour mean pollution concentrations, and we agree that the findings are consistent. Linn and Gong stated that their larger b values might be attributable to the fact that they measured PM10 rather than total suspended particles. We think that the absence of control for confounders such as meteorologic variables like temperature and barometric pressure, known to affect blood pressure, should also be considered as a reason for the larger effects found in their study. We would like to take the opportunity to point out the importance of recent epidemiologic findings that expanded the evidence about the relationship between ambient particulate matter and morbidity, not only in the United States but also in Europe.2 In particular, recent studies have focused on adverse cardiac outcomes, because previous morbidity and mortality studies showed that acute health risks of particulate matter were associated not only with respiratory causes but also with cardiovascular causes. Based on these findings, several epidemiologic studies are on the way to establishing more consistent evidence of the association between ambient particle exposure and cardiovascular function. Besides conducting new studies, another approach to gathering evidence of the relationship between ambient particulates and morbidity is to conduct secondary analyses of existing data. Our research group used data collected as part of the World Health Organization's MONICA study (Monitoring Trends and Determinants in Cardiovascular Disease) in Augsburg, Germany, to evaluate the relation between several cardiovascular and blood parameters and air pollution data gathered from existing networks.1,3,4 Alternatively, data collected on a routine basis could be used to assess the effects of air pollution. In a study conducted by a group at the Harvard School of Public Health, the incidence of cardiac arrhythmias based on data extracted from implanted cardioverter defibrillators5 was examined in association with air pollution data. We would like to encourage not only wider use of simple noninvasive cardiovascular measurements to assess the relation of cardiovascular impairment and air pollution but also use of existing data to measure the effects of air pollution on cardiovascular health.

A prospective study of Helicobacter pylori seropositivity and the risk for future myocardial infarction among socioeconomically similar U.S. men.

The role of Helicobacter pylori as a determinant of cardiovascular disease is controversial. To determine whether previous exposure to H. pylori is associated with an increased risk for myocardial infarction. Prospective case-control study. Physicians' Health Study. Initially healthy U.S. men. Titers of IgG antibody against H. pylori and several inflammatory markers were measured in baseline blood samples obtained from 445 men who subsequently had a myocardial infarction (case-patients) and 445 men matched for age and smoking status who remained free of vascular disease (controls) during a mean follow-up of 8.9 years. Baseline seropositivity was similar among case-patients and controls (43.4% vs. 44.3%; rate ratio, 0.96 [95% CI, 0.7 to 1.3]). Minimal evidence of association was found between magnitude of seropositivity and subsequent risk and between seropositivity and levels of the inflammatory biomarkers. In a socioeconomically homogeneous population, we found limited evidence of association between H. pylori exposure and risk for future myocardial infarction.

Occupational Hierarchy, Economic Sector, and Mortality from Cardiovascular Disease among Men and Women: Findings from the National Longitudinal Mortality Study

PURPOSE: Although socioeconomic position has been identified as a determinant of cardiovascular disease among employed men and women in the U.S., the role of economic sector in shaping this relationship has yet to be examined. We sought to estimate the combined effects of economic sector—one of the three major sectors of the economy: finance, government and production—and socioeconomic position on cardiovascular mortality among employed men and women. METHODS: Approximately 375,000 men and women 25 years of age or more were identified from selected Current Population Surveys between 1979 and 1985. These persons were followed for cardiovascular mortality through use of the National Death Index for the years 1979 through 1989. RESULTS: In men, the lowest cardiovascular mortality was found for professionals in the finance sector (76/100,000 person/years). The highest cardiovascular mortality was found among male non-professional workers in the production sector (192/100,000 person years). A different pattern was observed among women. Professional women in the finance sector had the highest rates of cardiovascular mortality (133/100,000 person years). For both men and women, the professional/non-professional gap in cardiovascular mortality was lower in the government sector than in the production and finance sectors. These associations were strong even after adjustment for age, race and income. CONCLUSIONS: Characteristics of government, finance and production work differentially influence the risk of cardiovascular disease mortality. Men, women, professionals and non-professionals experience this risk differently.

Circulating IGF binding protein-1 is inversely associated with leptin in non-obese men and obese postmenopausal women.

Hyperleptinaemia and hyperinsulinaemia interrelate to insulin-like growth factor binding protein 1 (IGFBP-1), and disturbances in the growth hormone-IGF-I axis are linked to obesity and cardiovascular diseases. However, whether the association between leptin and the GH-IGF-I axis is altered with increasing obesity is not known. We therefore examined the relationship between leptin, IGF-I, IGFBP-1, insulin and proinsulin in men and women with or without obesity in a population study. Healthy subjects (n=158; 85 men and 73 pre- and postmenopausal women) from the Northern Sweden MONICA (Monitoring of Trends and Determinants in Cardiovascular Disease) population were studied with a cross-sectional design. Anthropometric measurements (body mass index (BMI) and waist circumference) and oral glucose tolerance tests were performed. Radioimmunoassays were used for the analyses of leptin, IGF-I and IGFBP-1, and ELISAs for specific insulin and proinsulin. Leptin inversely correlated to IGFBP-1 in non-obese men (P<0.05) and obese postmenopausal women (P<0.05). In contrast, leptin did not correlate to IGF-I. IGFBP-1 was also significantly associated with proinsulin in non-obese men (P<0.01) and non-obese premenopausal women (P<0.05). The association between leptin and IGFBP-1 was lost after adjustment for insulin. In multivariate analyses taking measures of adiposity into account, low proinsulin, and IGF-I in combination with old age, but not leptin, predicted high IGFBP-1 levels. Leptin was inversely associated with IGFBP-1 in non-obese men and obese postmenopausal women, and proinsulin was inversely associated with IGFBP-1 in non-obese men and premenopausal women. However, these associations were lost with increasing central obesity in men and premenopausal women and after control for insulin. Therefore, this study suggests (i) that leptin is of minor importance for regulation of IGFBP-1 levels and (ii) that the insulin resistance syndrome is characterised by an altered relationship between leptin, IGFBP-1 and insulin.

Cardiovascular disease determinants in chronic renal failure: clinical approach and treatment.

Cardiovascular disease (CVD), as the leading cause of morbidity and mortality in patients on renal replacement therapy (RRT), has a central role in everyday nephrological practice. Consensus was reached on key points relating to the clinical approach and treatment of the main cardiovascular risk factors in RRT patients (hypertension, anaemia, hyperparathyroidism, dyslipidaemia, new emerging risk factors). In addition, the role of convective treatments on cardiovascular outcomes was examined. Hypertension should be managed by aiming at blood pressure values of < or =140/90 mmHg (< or =160/90 mmHg in the elderly), firstly by ensuring target dry body weight is achieved. No single class of drug has proved superior to others in RRT patients, provided that the blood pressure target is achieved, although ACE inhibitors have shown specific organ protection in high-risk patients (HOPE study) and are well tolerated. Anaemia should be managed by using erythropoietin and iron supplements, aiming at haemoglobin levels of 12 g/dl and keeping serum ferritin levels < 500 ng/ml. The management of hyperparathyroidism is currently unsatisfactory, as calcium supplements have the potential to increase cardiovascular calcification. While awaiting new calcium- and aluminium-free phosphate binders, it is essential to ensure dialysis adequacy. Clinical studies are in progress to assess the real impact of lipid-lowering drugs in RRT. In the meantime, serum LDL-cholesterol < 160 mg/dl and triglycerides < 500 mg/dl may be desirable targets. The impact of new emerging risk factors (inflammation and chronic infection, hyperhomocysteinaemia, metabolic waste-product accumulation) and their proper management are still under research. Convective dialysis treatments may confer some degree of protection from dialysis-related amyloidosis and mortality, but clinical data on this important issue are still controversial and no definitive conclusions can be drawn at present. CVD prevention and treatment is a great challenge for the nephrologist. Achieving evidence-based consensus can help in encouraging the implementation of best clinical practice in line with the progress of current knowledge.

Trends in cigarette smoking in 36 populations from the early 1980s to the mid-1990s: findings from the WHO MONICA Project.

This report analyzes cigarette smoking over 10 years in populations in the World Health Organization (WHO) MONICA Project (to monitor trends and determinants of cardiovascular disease). Over 300,000 randomly selected subjects aged 25 to 64 years participated in surveys conducted in geographically defined populations. For men, smoking prevalence decreased by more than 5% in 16 of the 36 study populations, remained static in most others, but increased in Beijing. Where prevalence decreased, this was largely due to higher proportions of never smokers in the younger age groups rather than to smokers quitting. Among women, smoking prevalence increased by more than 5% in 6 populations and decreased by more than 5% in 9 populations. For women, smoking tended to increase in populations with low prevalence and decrease in populations with higher prevalence; for men, the reverse pattern was observed. These data illustrate the evolution of the smoking epidemic in populations and provide the basis for targeted public health interventions to support the WHO priority for tobacco control.

American Diabetes Association 60th Scientific Sessions, 2000: cardiovascular disease in diabetes.

This is the fourth of seven reports on the American Diabetes Association (ADA) 60th Scientific Sessions held in San Antonio, TX, in June 2000. It covers topics related to cardiovascular disease (CVD) in diabetes. At a symposium held in conjunction with the meeting, Richard Nesto, Boston, MA, discussed screening for coronary heart disease (CHD) in diabetes. He stressed the importance of early treatment of acute myocardial infarction (MI), noting the increased mortality in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial with delay in diagnosis (1) and the high prehospitalization mortality in the Finnish Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (FINMONICA) study (2), which suggest the need for screening. This is particularly suggested by recent evidence that intensive risk factor modification improves the prognosis of patients with diabetes and CVD. The patient with diabetes may have either typical or atypical cardiac symptoms. Other patients requiring screening are those with abnormal resting electrocardiogram and those with other evidence of atherosclerosis; peripheral arterial disease, for example, is associated with a fourfold increase in CHD risk. Patients with macroalbuminuria have markedly increased CHD risk as well. Nesto pointed out that autonomic neuropathy is associated with decreased survival and a high CHD incidence and that this group may respond to treatment with β-blockers in view of their increased sympathetic tone. Cardiac autonomic neuropathy may also result in increased variability in sympathetic activity within the heart, as seen after MI, a potential cause of arrhythmia. Additional indications for CHD screening are the presence of two or more risk factors (dyslipidemia, hypertension, cigarette smoking, or positive family history) and the sedentary patient beginning a vigorous exercise program. The yield of noninvasive testing of patients identified in this fashion is between 10 and 20%. Nesto described a …

Sino-MONICA project: a collaborative study on trends and determinants in cardiovascular diseases in China, Part i: morbidity and mortality monitoring.

The Sino-MONICA project is a 7-year study monitoring trends and determinants of cardiovascular disease (CVD) in geographically defined populations in different parts of China. The study is a community-based prospective disease surveillance that uses the methodology and criteria of the World Health Organization's Monitoring Trends and Determinants in Cardiovascular Disease (WHO MONICA) project, with slight modifications for local use. After a pilot study of 2 years (1985 through 1986), data collection started formally on January 1, 1987, and ended on December 31, 1993. The main results were as follows. By international standards, both the incidence and mortality rate of coronary heart disease in Chinese populations were low. The highest incidence was 108.7 of 100,000 (1987 to 1989), and the lowest was 3.3 of 100,000 for men 35 to 64 years of age, a 33-fold difference. Both the incidence and mortality rate of cerebrovascular disease were high. The highest incidence was 553.3 of 100,000 (1987 to 1989), and the lowest was 33.0 of 100,000 for men 35 to 64 years of age, a 17-fold difference. There were significant geographic variations in both CVD incidence and mortality rate, with higher rates in the north and lower rates in the south. During 1987 to 1993, increasing trends were found in CVD rates in some populations, whereas decreasing trends were found in others. The trends were not significant statistically in most cases. Monitoring CVD with international standardized methods in China is feasible and urgently needed in view of the rapid socioeconomic development and transition of disease patterns taking place in China. The results are of significance in combating CVD both at home and abroad.

Hypertriglyceridemia: associated risks and effect of drug treatment.

Accumulating evidence indicates that hypertriglyceridemia (HTG) is a risk factor for cardiovascular disease. This increased risk is probably substantially mediated through the metabolic interrelationships between serum triglyceride (TG) levels and other risk factors, such as the atherogenic lipid profile (low high density lipoprotein-cholesterol levels and elevated small dense low density lipoprotein levels), insulin resistance, a prothrombotic propensity and low grade systemic inflammation. TG-lowering strategy in patients with HTG encompasses dietary modification and pharmacological agents, such as fibric acid derivatives, fish-oil and hydroxymethylglutaryl coenzyme A reductase inhibitors, which have, besides their known effects on the atherogenic lipid profile, beneficial effects on other determinants of cardiovascular disease. However, in spite of data from trials investigating fibric acid derivative-induced reduction in coronary events in patients with distinct types of hyperlipidemia, no specific trials have been performed that investigated this risk reduction in patients with HTG, in whom other cardiovascular risk factors are clustered as well. Small-scale studies on determinants of cardiovascular disease in patients with HTG and post-hoc analyses of the Helsinki Heart, Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial and Bezafibrate Infarction Prevention trials in patients with high serum TG levels suggest a drug-induced reduction in cardiovascular events. However, a specific trial should be conducted to investigate the effects of lipid-lowering therapy on clinical end-points in patients with HTG of defined types.

Do cardiovascular risk factors in men depend on their spouses' occupational category?

To analyse the relationships between major cardiovascular risk factors in French men and their spouses' occupational category (OC), taking their own OC into account. A large sample of volunteers working in the French National Electricity and Gas Company (GAZEL). As a check of the robustness, the same analysis was performed in a population-based survey (French multinational MONItoring of trends and determinants in CArdiovascular disease (MONICA) registers). Any site of the company in France. Representative sample from the population of the three registers (Lille, Strasbourg, Toulouse). 9486 and 534 men respectively, in working activity, living in couple and aged 40 to 50 years. Self-reported arterial hypertension, diabetes, hypercholesterolemia, leisure time sedentary lifestyle, smoking status, body mass index (BMI) and alcohol consumption. In the GAZEL study, diabetes, smoking status, and alcohol consumption in men were associated with their own OC. In contrast, spouses' OC was independently associated with men's hypertension, hypercholesterolemia, sedentary lifestyle, and BMI: men whose spouses were unoccupied or workers have higher risk factors levels. In the MONICA study, the results were mostly comparable, at least for hypercholesterolemia, sedentary lifestyle, smoking status and alcohol consumption. Spouses' OC was independently associated with several cardiovascular risk factors in men. These results might indicate that socioeconomic status of the couple, and not only individual characteristics, should be taken into account for a better understanding of cardiovascular risk.

A strong association between biologically active testosterone and leptin in non-obese men and women is lost with increasing (central) adiposity.

In both humans and rodents, males have lower levels of leptin than females at any level of adiposity. Experimental data support the idea that testosterone exerts a negative influence on leptin levels. There are, however, major inconsistencies in available data concerning the possible association between androgenicity and leptin in humans. Reasons could be the influence of androgenicity on leptin production being dependent on body composition, and incomplete measures of biologically active testosterone levels. In the present study we have characterized the relationship between biologically active testosterone and leptin after careful stratification for gender and adiposity. Healthy subjects (n=158; 85 men and 73 pre- and postmenopausal women) from the Northern Sweden MONICA (Monitoring of Trends and Determinants in Cardiovascular Disease) population were studied with a cross-sectional design. Anthropometric measurements (body mass index (BMI) and waist circumference) and oral glucose tolerance tests were performed. Circulating levels of leptin, insulin, testosterone, androstenedione, sex hormone-binding globulin (SHBG) and insulin-like growth factor-1 (IGF-1) were measured by radioimmunoassays or microparticle enzyme immunoassays. Apparent concentrations of free testosterone and non-SHBG-bound testosterone were calculated. After adjustments for age, BMI and insulin, leptin levels were inversely correlated to testosterone levels in non-obese men (r=-0.56, P<0.01) and obese women (r=-0.48, P<0.05). In contrast, leptin and testosterone correlated in a positive manner in non-obese women (r=0.59, P<0.01). Levels of SHBG were negatively associated with leptin in men with low waist circumference (r=-0.59, P<0.01). The following factors were associated with leptin in a multivariate model: low levels of biologically active testosterone and SHBG in men with low and medium waist circumference, insulin in men with high waist circumference, high levels of testosterone and insulin in non-obese women, and BMI in obese women. We conclude that low leptin levels are associated with androgenicity in non-obese men and women and that the direction of this association is dependent on gender and body fat distribution. Based on these results we suggest that the relation between testosterone and leptin contributes to the gender difference in circulating leptin levels. International Journal of Obesity (2001) 25, 98-105

Ten-year trend of analgesic drug use (1984 to 1995): results of three MONICA-based surveys in Augsburg)

Use of drugs, especially analgesics, is thought to be responsible for the rising cost of the health system in Germany, but there are no published population data for analgesic intake in Germany. Data derived from the three MONICA surveys (Monitoring of Trends and Determinants of Cardiovascular Diseases) in Augsburg and its adjacent districts were analysed for the prevalence of analgesic usage between 1984 and 1995 (the first such survey for Germany). A total of 5,899 males and 6,005 females (aged 25-64 years), representative of the population, were selected and examined in 1984/85, 1989/90 and 1994/95 (participation rate of those selected, 75-79%). Using a standardized protocol, all analgesic drugs taken during the previous 7 days were recorded and classified. The analysis was standardized for age and classified according to sex. Strong analgesics were not significantly used under the ambulatory conditions of this survey and were therefore excluded from the analysis. Intake prevalence of mild to moderately strong analgesics varied from 5.9-8.9% in males and 9.9-13.4% in females. Prevalence was significantly at its lowest in 1989/90, but similar at the beginning and end of the 10-year period. Changes in prevalence of analgesic usage were similar to those of on-demand medication. Salicylic acid preparations containing higher dosages of the active ingredient were the drugs most commonly used, followed by aniline preparations, heteroaryl- as well as aryl-acetate and propionic acid derivates, pyrazole derivates, oxicam and anthranylic acid derivates. The prevalence of taking mild of moderately strong analgesics was at a similar low level at the beginning and end of the 10-year period.

Assessing the impact of classical risk factors on myocardial infarction by rate advancement periods.

The risk or rate advancement period (RAP) proposed by Brenner et al. (Epidemiology 1993;4:229-36) conveys information on the impact of a risk factor on the age dimension of chronic disease occurrence and may thus facilitate communication of epidemiologic findings. The RAP expresses how much sooner a given risk or rate of disease occurrence is reached among exposed than among unexposed individuals. The purpose of the present analysis was to derive estimates of RAPs for cardiovascular risk factors in relation to incident nonfatal and fatal myocardial infarction in middle-aged men of the Monitoring Trends and Determinants in Cardiovascular Diseases (MONICA) Augsburg cohort, Germany, between 1984 and 1995. RAPs were estimated based on Cox proportional hazards models. After multivariate adjustment, hypertension, smoking, and dyslipidemia were associated with RAPs of 8, 11, and 11 years, respectively, conditional on infarction-free survival to baseline and absence of competing risks. The RAP may be interpreted as that, on average, smokers are expected to advance their risk of myocardial infarction approximately 11 years compared with never/former smokers; for example, 50-year-old smokers are expected to carry the same risk of infarction as 61-year-old nonsmokers. The authors encourage the use and evaluation of the RAP as an effective risk communication tool in actual counseling situations.

Localization of a Small Genomic Region Associated with Elevated ACE

Defining the relationship between multiple polymorphisms in a small genomic region and an underlying quantitative trait locus (QTL) represents a major challenge in human genetics. Pedigree analyses have shown that angiotensin I-converting enzyme (ACE) levels are influenced by a QTL located within or close to the ACE gene and most likely resides in the 3' region of this locus. We genotyped seven polymorphisms spanning 13 kb in the 3' end of ACE in 159 Afro-Caribbean subjects to evaluate the linkage disequilibrium between these sites and to narrow the genomic region associated with an elevated ACE level using a cladistic analysis. The linkage disequilibrium measurement D' and a haplotype tree revealed three distinct haplotype segments, presumably because of recombination. The value of the linkage disequilibrium parameter p(excess) was highest for site 22982, which is located in the middle segment. A series of nested, cladistic analyses confirmed that the other two regions are unlikely to be the ACE-linked QTL and that the variant resides in the middle region. Analyses of the same polymorphisms in 98 unrelated Europeans in the Monitoring Trends and Determinants in Cardiovascular Diseases (MONICA) study resulted in fewer haplotypes than were observed among the Afro-Caribbean subjects, suggesting that populations with greater genetic diversity may be especially informative for fine-scale mapping.

One-Year Prevalence of Low Back Pain in Two Swiss Regions

A cross-sectional survey was performed. To estimate the extent of low back pain as a public health problem. Health surveys converge on very high estimates of low back pain in general populations, but few studies have included severity criteria in their definition and conclusions. Because it is unlikely that interventions will influence the prevalence of minimal and infrequent symptoms, greater attention should be paid to characteristics of low back pain that indicate some impact on the life of survey respondents. Two regions participated in the MONICA (MONitoring of trends and determinants in CArdiovascular disease) project in Switzerland. Participants randomly selected from the general population completed a standard self-administered questionnaire on cardiovascular risk factors. A special section on low back pain was added in the third (1992-1993) MONICA survey and completed by 3227 participants. A regional difference found in the 12-month prevalence rate disappeared with the inclusion of severity criteria. Low back pain over more than seven cumulated days was reported among men by 20.2% (age range, 25-34 years) to 28.5% (age range, 65-74 years), respectively, among women by 31.1% to 38.5%. Similar rates of reduction in activity (professional, housekeeping, and leisure time) and medical consultation (conventional and nonconventional) motivated by low back pain characterized the two participating regions. The cumulative duration of pain was related to all the indicators showing the impact of low back pain on everyday life. Determining the cumulative duration of low back pain over the preceding year is a straightforward task, and a cutoff at 1 week seems appropriate for distinguishing between low- and high-impact low back pain.

Incidence and correlates of hypertension in the Atherosclerosis Risk in Communities (ARIC) study and the Monitoring Trends and Determinants of Cardiovascular Disease (POL-MONICA) project.

The purpose of this research is to assess short-term blood pressure change and hypertension incidence, and identify correlates of incident hypertension in the USA and Poland. Population-based samples aged 45-64 years at enrollment from the Atherosclerosis Risk in Communities (ARIC) and the Pol-MONICA studies: including 3777 whites from Minneapolis, Minnesota, USA suburbs (urban), 3635 whites from Washington County, Maryland, USA (semi-rural) and 3109 blacks from Jackson, Mississippi, USA surveyed in 1987-1989 and 1990-1992; and 389 persons from Warsaw, Poland (urban) and 322 from Tarnobrzeg Province, Poland (semi-rural) surveyed in 1987-1988 and 1992-1993. Age-standardized systolic and diastolic blood pressures at both screens were 9-20 and 5-9 mmHg higher in the Polish samples than in US blacks, who had higher levels than US whites. Age-adjusted annual hypertension incidence in both Polish male cohorts (6-8%) was higher than that in US white men (4%) and approaching that of US black men (7%); rates were also higher in Polish female cohorts (8-9%) than in US black women (8%), but nearly twice those in US white women (4%). Factors independently related to hypertension incidence included age, family history, smoking, baseline blood pressures and body mass index, and increase in body mass index and alcohol consumption between screenings. After adjustment for these factors, annualized hypertension incidence was similar in US white and Polish men (2.3 and 2.7%) compared with US black men (3.4%), and in US white and Polish women (1.5 and 1.3%) compared with US black women (3.9%). Despite substantial differences in blood pressure levels and age-standardized hypertension incidence rates, the differences in incidence between Polish and US white men appear to be explained largely by differences in risk factors for hypertension.

Educational level, relative body weight, and changes in their association over 10 years: an international perspective from the WHO MONICA Project

This study assessed the consistency and magnitude of the association between educational level and relative body weight in populations with widely different prevalences of over-weight and investigated possible changes in the association over 10 years. Differences in age-adjusted mean body mass index (BMI) between the highest and the lowest tertiles of years of schooling were calculated for 26 populations in the initial and final surveys of the World Health Organization (WHO) MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) Project. The data are derived from random population samples, including more than 42,000 men and women aged 35 to 64 years in the initial survey (1979-1989) and almost 35,000 in the final survey (1989-1996). For women, almost all populations showed a statistically significant inverse association between educational level and BMI; the difference between the highest and the lowest educational tertiles ranged from -3.3 to 0.4 kg/m2. For men, the difference ranged from -1.5 to 2.2 kg/m2. In about two thirds of the populations, the differences in BMI between the educational levels increased over the 10-year period. Lower education was associated with higher BMI in about half of the male and in almost all of the female populations, and the differences in relative body weight between educational levels increased over the study period. Thus, socioeconomic inequality in health consequences of obesity may increase in many countries.

Anticardiolipin antibodies are not an independent risk factor for stroke: an incident case-referent study nested within the MONICA and Västerbotten cohort project.

Anticardiolipin antibodies (aCL) have been proposed to be an independent risk factor for stroke. To test this hypothesis, a nested case-control study was performed to compare aCL with the other known risk factors for stroke. Within the framework of the World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) project and the Västerbotten Intervention Program (VIP) health survey, 44 725 men and women were enrolled and followed up from January 1, 1985, through August 31, 1996. Individuals free from cardiovascular events were followed up, and 123 developed stroke (on average, 34.1 months after blood sampling; 21 cerebral hemorrhage and 102 cerebral infarction); they were compared with 241 age- and sex-matched control subjects from the same population. ELISA was used for the analysis of IgG, IgM, and IgA aCL. IgM-aCL were present in 11.4% of patients (14/123) who developed stroke and in 4. 1% of individuals (10/241) who remained healthy (P=0.013, OR 2.97, 95% CI 1.28 to 6.89). The OR for the levels of IgM-aCL was 1.34 (P=0. 01, 95% CI 1.07 to 1.68) without adjustment for other risk factors and 1.24 when adjusted for hypertension, diabetes mellitus, cigarette smoking, and use of smokeless tobacco (P=0.077, 95% CI 0. 98 to 1.56). There was no difference between patients and controls for the prevalence or level of IgG-aCL and IgA-aCL and also no difference between patients with cerebral hemorrhage and cerebral infarction for the prevalence of all 3 isotypes of aCL. We conclude that aCL are associated with future stroke but do not constitute an independent risk factor.

Effect of beer drinking on risk of myocardial infarction: population based case-control study

Many studies have shown an inverse association between alcohol consumption and coronary heart disease, with a possible flattening at higher consumption levels.1 It remains unclear, however, whether the protective effect...