Higher Coronary Heart Disease Mortality Research Articles

Abstract 16710: Racial Disparities in Outcomes in Women Undergoing Percutaneous Intervention

Introduction: Cardiovascular disease is the leading cause of death in men and women, blacks and whites. Women are underrepresented in clinical studies. African-American women have a higher coronary heart disease mortality risk than their white counterparts. However, there exists limited outcomes data for black women (BW) compared to white women (WW) after percutaneous coronary intervention (PCI). Hypothesis: The aim of this retrospective analysis was to evaluate the 1 year major cardiovascular events (MACE) in patients undergoing PCI based on gender and race Methods: Within our PCI database we identified 4776 patients who underwent PCI from 2003 to 2016. Of those 1,916 were BW and 2,860 were WW. MACE/target vessel revascularization (TVR) at 30 days and 1 year were assessed and proportional Cox hazard model analyses was performed to assess outcomes after adjustment for confounding factors (i.e. age, BMI, presentation with acute M, diabetes, smoking, history of CAD, family history of CAD, hyperlipidemia, hypertension, prior coronary intervention, chronic kidney disease (CKD)). Results: Characteristics of the patient population is shown in the table. BW presented at younger age and had significantly higher rate of risk factors. BW were significantly sicker than WW. Periprocedural and in-hospital were similar between the 2 groups except for vascular complications more likely in WW (4.3% vs 2.6%; p=0.003). At 30 days and 1 year, the rate of MI, TVR and stent thrombosis (ST) was significantly higher in BW (Figure). There was a large difference in median income, $102,250 for WW vs. $80,150 for BW, but it had no effect on the outcome (HR = 1.00, p = 0.362). After adjusting for confounding factors BW were 1.6 times more likely to experience MI at 1 year than WW (HR 1.6, 05%CI 1.04-2.49, p= 0.03). Conclusions: In this large cohort of women with coronary artery disease undergoing PCI we observed significant race disparities in MI rate at 1 year even after adjustment for clinical presentation and cardiovascular risk factors

Impact of persistence and non-persistence in leisure time physical activity on coronary heart disease and all-cause mortality: The Copenhagen City Heart Study.

Aims The aim of this study was to investigate the impact of persistence and non-persistence in leisure time physical activity on coronary heart disease and all-cause mortality. Methods and results In the Copenhagen City Heart Study, we prospectively followed 12,314 healthy subjects for 33 years of maximum follow-up with at least two repeated measures of physical activity. The association between persistence and non-persistence in leisure time physical activity, coronary heart disease and all-cause mortality were assessed by multivariable Cox regression analyses. Coronary heart disease mortality for persistent physical activity in leisure compared to persistent sedentary activity were: light hazard ratio (HR) 0.76; 95% confidence interval (CI) 0.63-0.92, moderate HR 0.52; 95% CI 0.41-0.67, and high physical activity HR 0.51; 95% CI, 0.30-0.88. The differences in longevity were 2.8 years for light, 4.5 years for moderate and 5.5 years for high physical activity. A substantial increase in physical activity was associated with lower coronary heart disease mortality (HR 0.75; 95% CI 0.52-1.08) corresponding to 2.4 years longer life, whereas a substantial decrease in physical activity was associated with higher coronary heart disease mortality (HR 1.61; 95% CI 1.11-2.33) corresponding to 4.2 years shorter life than the unchanged group. A similar pattern was observed for all-cause mortality. Conclusion We found inverse dose-response relationships between persistent leisure time physical activity and both coronary heart disease and all-cause mortality. A substantial increase in physical activity was associated with a significant gain in longevity, whereas a decrease in physical activity was associated with even greater loss of longevity.

40-Year CHD Mortality Trends and the Role ofRisk Factors in Mortality Decline: The North Karelia Project Experience.

In the 1960s and early 1970s, coronary heart disease (CHD) mortality in Finland was the highest in the world, and within Finland, mortality was particularly high in the eastern part of the country. The North Karelia Project, the first large community-based cardiovascular diseases prevention program was established in 1972 to reduce the extremely high CHD mortality through behavioral change and reduction of the main cardiovascular disease risk factors among the whole population of North Karelia, the easternmost province of Finland. During the 40-year period from 1972 to 2012, smoking prevalence, serum total cholesterol, and systolic blood pressure declined markedly, except a small increase in serum cholesterol levels between 2007 and 2012. From the early 1970s to 2012, CHD mortality decreased by 82% (from 643 to 118 per 100,000) among working-age (35 to 64 years) men. Among working-age women, the decline was 84% (from 114 to 17 per 100,000). During the first 10 years, changes in these 3 target risk factors explained nearly all of the observed mortality reduction. Since the mid-1980s, the observed reduction in mortality has been larger than the predicted reduction. In the early 1970s, premature CHD mortality (35 to 74 years) was about 37% higher among Eastern Finnish men and 23% higher among Eastern Finnish women, compared with men and women in Southwestern Finland. During the last 40 years, premature CHD mortality declined markedly in both areas, but the decline was larger in Eastern Finland and the mortality gap between the two areas nearly disappeared.

Are Depressive Symptoms Associated with Cardiovascular Mortality Among Older Chinese: A Cohort Study of 64,000 People in Hong Kong?

Depression was positively associated with cardiovascular disease (CVD) or mortality in previous studies. However, whether the observed association can be explained by health status is not clear. To study the association of depressive symptoms with CVD, stroke, and coronary heart disease (CHD) mortality in older Chinese in Hong Kong, and whether the associations varied by gender or health status. Prospective population-based study. Elderly Health Centers. A total of 62,839 people age 65 or older (21,473 men and 41,366 women) enrolled during July 1998 to December 2001 at all 18 Elderly Health Centers of the Department of Health of Hong Kong. Fifteen-item Geriatric Depression Scale (GDS) was used and presence of depressive symptoms was defined by GDS score 8 or more. The cohort was followed up for mortality till March 31,2009. Depressive symptoms were only associated with CHD mortality in men (hazard ratio [HR] 1.41, 95% confidence interval [CI]: 1.08-1.84; p for gender interaction= 0.02) adjusted for age, education, monthly expenditure, smoking, alcohol use, physical activity, body mass index, health status, and self-rated health. GDS score was associated with stroke mortality (similarly adjusted HR 1.02 per score, 95% CI: 1.00-1.04) in all subjects (adjusted also for gender), and CHD mortality (1.04 [1.01-1.07]) in men. Health status attenuated but did not modify any associations. Depressive symptoms were independently associated with higher CHD mortality in older Chinese men, and with higher stroke mortality in both genders. However, attenuation by health status, and lack of consistency by gender indicate that these associations could be noncausal and further studies by treatment trials and Mendelian randomization are needed.

Age-dependent interaction of apolipoprotein E gene with eastern birthplace in Finland affects severity of coronary atherosclerosis and risk of fatal myocardial infarction—Helsinki Sudden Death Study

Background. Mortality from coronary heart disease (CHD) has been constantly higher in eastern late settlement regions compared to western early settlements in Finland, unrelated to classical risk factors. In line with this, eastern birthplace was an age-dependent predictor of severe coronary atherosclerosis and pre-hospital sudden coronary death among male residents of Helsinki. We investigated a possible interaction of apolipoprotein E (APOE) gene with birthplace on the risk of myocardial infarction (MI) and coronary atherosclerosis.Method. APOE genotypes were analyzed in the Helsinki Sudden Death Study series comprising out-of-hospital deaths among males aged 33–70 years (n = 577), who were born in high (east, n = 273) or low (west, n = 304) CHD mortality area.Results. Eastern-born men ≤ 55 years carried 30% more often (P = 0.017) and older men 40% less often (P = 0.022) the APOE ϵ4 allele compared to western-born men (P = 0.003 for birthplace-by-age interaction). In multivariate analysis, the ϵ4 allele associated with the risk of out-of-hospital MI (odds ratio 2.58; 95% CI 1.20–5.55; P = 0.016) only in eastern-born men and with advanced atherosclerosis in both regions of origin, respectively.Conclusions. Birthplace-bound risk of CHD was age-dependently modified by APOE ϵ4 allele, suggesting genetic differences in CHD susceptibility between early and late settlement regions in Finland and providing one explanation for the eastern high mortality.

Letter by Ferdinand et al Regarding Article, “Does Black Ethnicity Influence the Development of Stent Thrombosis in the Drug-Eluting Stent Era?”

To The Editor: Blacks have the highest coronary heart disease mortality of major US race/ethnic groups, and represent appropriate candidacy for drug-eluting stents (DES). We read with interest the recent report by Collins et al,1 which concludes that black race is an independent predictor of definite DES thrombosis. Although interesting, this single-center, retrospective analysis contained a relatively small number of black subjects (n=1594) and even fewer stent thrombosis events (n=108). Though provocative, these findings may still represent a play of chance, and should not yet be translated into clinical dogma. The avoidance of DES in black patients who are otherwise appropriate candidates …

Birthplace in area with high coronary heart disease mortality predicts the severity of coronary atherosclerosis among middle-aged Finnish men who had migrated to capital area: The Helsinki Sudden Death Study

Background. Reasons why eastern-born male Finns have higher coronary heart disease (CHD) mortality than do western-born men are still unsettled. Recently, eastern birthplace was found to be an independent predictor of pre-hospital sudden cardiac death (SCD) in the new low-mortality area of residence.Aim. To investigate the association of birthplace with high CHD mortality attributes to more severe coronary atherosclerosis among men migrated to the low-mortality capital area.Method. Coronary atherosclerosis was measured in 373 western-born and 314 eastern-born out-of-hospital male deaths aged 33–70 years in Helsinki (The Helsinki Sudden Death Study), covering 24.6% of male deaths within this age-group. CHD risk factors were obtained from an interview of a next of kin.Results. In multivariate analysis there was a strong birthplace-by-age interaction with atherosclerosis (P = 0.0005). Eastern-born men <54 years had larger areas of fatty streaks (P = 0.0195), fibrotic plaque (P = 0.0133), calcification (P = 0.0009), total plaque area (P = 0.0011), and greater stenosis (P = 0.0004) in the left coronary compared to western-born men, independent of CHD risk factors. Amongst older men (≥54 years) such an association no longer appeared.Conclusion. Higher CHD mortality among eastern-born men may be due to more severe coronary atherosclerosis independently of CHD risk factors, reflecting Finns' two-phase settlement history.

Patients With Hypertension and the Cardiometabolic Syndrome: The Potential Impact of Inflammatory Biomarkers

E.M. is a 54-year-old African American woman who presents to her physician for an annual examination. She has been reading extensively concerning the prevention of heart disease and wants to keep her risk as low as possible. E.M. has a personal history of hypertension and has been taking antihypertensive medications since the age of 46. Physical examination reveals an obese woman with a body mass index of 31.4 kg ⁄m, waist circumference of 36 inches, and blood pressure (BP) of 146 ⁄92 mm Hg. The remainder of the physical examination is unremarkable. Laboratory evaluation shows a fasting glucose of 106 mg ⁄dL, high-density lipoprotein cholesterol level of 52 mg ⁄dL, low-density lipoprotein level of 136 mg ⁄dL, and triglycerides 122 mg ⁄dL. She asks you if she should have a Creactive protein (hs-CRP) level checked with her other annual laboratory values. Based on her elevated BP, fasting glucose, and lipid profile, what do you advise her about her risk and how do you manage her risk factor profile? African Americans have a higher prevalence of coronary heart disease and a higher coronary heart disease mortality rate than white Americans. Much of this excess morbidity and mortality is due to the burden of hypertension-related target organ damage along with the increased prevalence of multiple risk factors for coronary heart disease, including higher levels of obesity, especially in women; insulin resistance; and sedentary lifestyle. However, compared with other groups, most of the data have shown that African Americans may have similar or even better lipid profiles than whites, including lower total cholesterol, lower low-density lipoprotein, and higher high-density lipoprotein levels. The combination of better lipid profiles despite worse insulin resistance, higher BP, and more prevalent obesity has led to data showing an unexpectedly overall low prevalence of the metabolic syndrome in population-based epidemiologic studies. Newer data suggest that targeting emerging cardiovascular disease (CVD) risk factors in addition to traditional CVD risk factors may improve outcomes. These considerations are particularly relevant because a large body of data has suggested that African Americans tend to have higher levels of hs-CRP and other inflammatory biomarkers. Developing approaches to assess cardiac risk include using biomarkers in addition to traditional CVD risk factors to help target more intense therapeutic goals for patients previously considered to be at low to intermediate risk for future CVD events. hs-CRP is the most extensively studied of the inflammatory biomarkers, with higher levels of hsCRP being associated with increased risk of CVD. In previous analyses, race and sex have both been shown to be independent predictors of elevated hs-CRP, with African American race and female sex associated with higher levels. Accordingly, From the Division of Cardiology, Emory University School of Medicine, Atlanta, GA Address for correspondence: Alanna Morris, MD, Emory University School of Medicine, 1364 Clifton Road NE, Suite D407B Atlanta, GA 30322 E-mail: aamorr3@emory.edu

Cardiovascular Disease in Women—Challenges Deserving a Comprehensive Translational Approach

Heart disease in women is associated with high levels of morbidity and mortality. Although many of the underlying causes are similar for both genders, cardiovascular disease among women has some unique features, including higher coronary heart disease mortality, higher frequency of sudden cardiac death without previous symptoms, and increased mortality among older women compared to men following a myocardial infarction. During recent years, increasing efforts have been placed on identifying preventive measures, but translation of knowledge from epidemiological studies and clinical trials remain incomplete, particularly in women. The recent launch of the National Institutes of Health’s Clinical and Translational Science Award program offers opportunities to address these gaps and represent a unique opportunity to foster a new generation of researchers familiar with important issues regarding women’s cardiovascular health.

Hypertension

The field of hypertension has enjoyed some remarkable successes in recent years. Better blood pressure management has been an important contributor to the recent rapid decline in the age-adjusted death rates for coronary heart disease (CHD) and stroke.1 Yet, there is yet so much more that could be accomplished through better blood pressure management. CHD and stroke remain the first and third leading causes of death in the United States.2 And only slightly more than a third of those with hypertension in the United States achieve recommended treatment goal blood pressure levels.3 Control rates are even worse in most other countries.4 Better blood pressure management can save many lives. Here, some pathways to success are considered. Few measurements in medicine are done as poorly and inconsistently as blood pressure measurement. Methods used today in clinical practice and in clinical trials are little changed from the earliest days of measurement.5 Though there is a clear recognition of biological variability, we continue to make decisions largely on measurements taken at random times under poorly controlled conditions. The measurement process is less regulated than measurement of most other major risk factors. Just compare the quality control process for glucose or cholesterol measurement with that for blood pressure measurement in your own local setting. There are not readily available solutions for this issue. Substantial investments in research in this area should be made by government and commercial entities. We must have reliable, reproducible, convenient, and precise measurement tools for blood pressure. These tools should allow for measurement of the important components of blood pressure and mechanisms for integrating and interpreting influence of time of day, activity, …

Coronary Heart Disease Mortality in Czech Men, 1980-2004

Background: The Czech Republic belongs to countries with high coronary heart disease (CHD) mortality. The aim was to analyze age, period and cohort specific CHD mortality in men from the Czech Republic. Design and Methods: National data on mortality of men (30-74 yrs.) in the Czech Republic in 1980-2004 were explored. The Poisson regression model was applied to evaluate age, period and cohort effects on mortality. Results: An adequate fit of CHD men's mortality provided the age-period-cohort model (p=0.121). The ratio of mortality of the age group 45-49 to 40-44 was by 17 % lower than that of the age group 40-44 to 35-39. The ratio of the relative risk of period 1995-1999 to 1990-1994 was by 19 % lower than that of the period 1990-1994 to 1985-1989. The ratios of the relative risks between adjoining birth cohort-groups were close to 1. Conclusions: The fatal CHD risk in Czech men was significantly depended on age (the risk increasing with age), calendar period (the risk reduced in the recent years), and birth cohort (the risk decreasing with birth cohort). The crucial positive change in the CHD mortality trend was observed after the collapse of communism in 1989, and in men past age 40 years.

The Relationships Among Stress, Coping, Social Support, and Weight Class in Premenopausal African American Women At Risk for Coronary Heart Disease

The purpose of this study was to determine the nature of the relationships among stress, coping, social support, and weight class in premenopausal African American women as risk factors for coronary heart disease. Overweight and obesity are significant problems for African American women who are at an increased risk of weight-related diseases, such as diabetes, hypertension, cardiovascular disease, and cancer. Of these women, those who are premenopausal have a significantly higher coronary heart disease mortality rate than their white counterparts. There are gaps in current knowledge concerning the role that stress and other psychosocial factors play in weight control of premenopausal African American women. Data were obtained from 178 women with eligible data sets from a larger study of 236 subjects (Genetic Predictors of Coronary Heart Disease in Premenopausal African American Women). The measures for stress, coping, and social support included the Perceived Stress Scale, the Norbeck Social Support Questionnaire, and the Jalowiec Coping Scale. The weight class of the women was determined as: normal weight-body mass index (BMI) of 18.5-24.9 kg/m, overweight-BMI of 25-29.9 kg/m, or obese-BMI > or = 30 kg/m. Statistical analysis conducted included Spearman's rho, Chi-square, and regression analysis. Confrontive coping was shown to be used more often to a "high" degree in normal-weight African American women than in overweight and obese African American women (chi = 24.024; P = .0001). Confrontive coping was the only independent predictor of weight class in a regression model that included perceived stress, life events, social support, and optimistic, self-reliant, and evasive coping strategies. Therefore, African American women who use confrontive coping to a high degree were more likely to confront problems, such as weight control issues, than those who use this coping strategy to a low or medium degree.

Effects of ezetimibe on lipids and lipoproteins in patients with hyper­cholesterolemia and different apolipoprotein E genotypes

ABSTRACTBackground: The ε4 allele of the gene encoding apolipoprotein E (apoE) is associated with elevated serum levels of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL‑C), as well as an increased risk of coronary heart disease (CHD), greater disease severity, and higher CHD mortality. ApoE ε4 allele carriers have also shown reduced lipid and lipoprotein responses to lipid-modifying pharmacotherapy and lifestyle modifications.Objective: To provide preliminary descriptive data on the effects of apoE genotype on lipid and lipoprotein responses to the cholesterol absorption inhibitor ezetimibe (Ezetrol/Zetia) in Hungarian subjects not at cholesterol goals at baseline.Methods: This prospective open-label study compared the effects of the cholesterol absorption inhibitor ezetimibe 10 mg/day for up to 6 weeks added to existing therapies on the lipid profiles of 14 ε4 allele carriers and 14 age- and gender-matched APOE3/APOE3 homozygotes.Results: Treatment with ezetimibe reduced TC, LDL‑, and triglycerides, and increased high-density lipoprotein cholesterol (HDL‑) significantly from baseline, and to similar extents, in both groups, lowering TC from baseline by 13.7% in APOE3/APOE3 homozygotes compared with 12.1% in ε4 allele carriers ( p = 0.139); LDL‑C by 22.8% (vs. 19.6%; p = 0.081); and triglycerides by 9.2% (vs. 9.1%; p = 0.120). Ezetimibe also increased HDL‑C by 8.0% in subjects with the ε3/ε3 genotype compared with 8.9% in ε4 allele carriers ( p = 0.263).Conclusions: Ezetimibe significantly improved lipid and lipoprotein profiles from baseline irrespective of apoE ε3/ ε3 or ε4 genotype in Hungarian subjects not at cholesterol goals. Limitations of our study include its open-label nature and small sample population, as well as the facts that patients with the ε4 allele were not included and data were not collected on initial cholesterol levels, initial statin doses, cholesterol responses to statins, and the safety and tolerability of ezetimibe. Further randomized controlled studies in larger numbers of people followed for longer intervals are warranted to confirm these findings.

Stronger symptoms of depression predict high coronary heart disease mortality in older men and women

Most cohort studies have found depressive symptoms to be associated with increased cardiovascular mortality in the elderly, but follow-up times have often been short and study populations small. To describe associations between stronger symptoms of depression and the risk of death from coronary heart disease (CHD) or myocardial infarction (MI) in elderly Finnish subjects free of CHD at the baseline. This study is a prospective population-based epidemiological and clinical twelve-year follow-up study in Lieto Health Centre, Finland. The basic population consisted of 1196 elderly (64 years of age or older) persons who lived in the municipality of Lieto in southwestern Finland in 1990. The occurrence of CHD was determined on the basis of electrocardiographic (ECG) findings, Rose questionnaire and the diagnoses in medical records. The persons with CHD were excluded from the study population. Symptoms of depression at the baseline were measured with the Zung Self-rating Depression Scale (ZSDS). Mortality was followed up for about 12 years. The Kaplan-Meier survival curves showed stronger symptoms of depression to be related to high risks of mortality from CHD or MI among men and women. According to the Cox model for men significant predictors for higher risk of CHD or MI mortality were stronger symptoms of depression, higher age and a large number of medications in use. When women were examined, significant predictors were stronger symptoms of depression and a large number of medications in use. Stronger symptoms of depression are an independent risk factor for high CHD or MI mortality in aged Finnish men and women free of CHD at baseline.

Dietary fat intake and risk of coronary heart disease: the Strong Heart Study

The results of previous studies on the association between dietary fat intake and coronary heart disease (CHD) incidence are inconsistent. The aim of this study was to examine the association between dietary fat intake and CHD incidence in American Indians in the Strong Heart Study. A total of 2938 participants aged 47-79 y and free of CHD at the second examination (1993-1995) were examined and followed for CHD, nonfatal CHD, and fatal CHD events to 31 December 2002. Dietary intake was assessed by using a 24-h diet recall and was calculated as percentages of energy. Participants were followed for a mean (+/-SD) of 7.2 +/- 2.3 y. During follow-up, 436 incident CHD cases (298 nonfatal CHD and 138 fatal CHD events) were ascertained. Participants aged 47-59 y in the highest quartile of intake of total fat, saturated fatty acids, or monounsaturated fatty acids had higher CHD mortality than did those in the lowest quartile [hazard ratio (95% CI): 3.57 (1.21, 10.49), 5.17 (1.64, 16.36), and 3.43 (1.17, 10.04), respectively] after confounders were controlled for. These associations were not observed for those aged 60-79 y. Total fat, saturated fatty acid, and monounsaturated fatty acid intake were strong predictors of CHD mortality in American Indians aged 47-59 y, independent of other established CHD risk factors. It may be prudent for American Indians to reduce their fat intake early in life to reduce the risk of dying from CHD.

Do known risk factors explain the higher coronary heart disease mortality in South Asian compared with European men? Prospective follow-up of the Southall and Brent studies, UK

We examined prospectively whether measured risk factors can explain the higher CHD mortality in South Asians compared with Europeans. Conventional CHD risk factors and those associated with insulin resistance were measured in 1,787 European and 1,420 South Asian men aged 40 to 69 years at baseline in the population-based Southall and Brent studies (London) between 1988 and 1990. Participants were followed up for mortality. By February 2006, there were 202 CHD deaths (108 Asian, 94 European). South Asian men had double the CHD mortality of European men in Cox regression analyses adjusted for age, smoking, and cholesterol (hazard ratio [HR] 2.14, 95% CI 1.56-2.94, p<0.001). Nearly half of all South Asian CHD deaths versus 13% of deaths among Europeans were among persons with diabetes. Asian men had greater CHD mortality than Europeans, both in the with- and the without-diabetes categories at baseline. CHD mortality remained significantly higher in South Asian men in multivariable models that adjusted for conventional risk factors and diabetes and/or impaired glucose regulation, features of insulin resistance, or the metabolic syndrome (HR 1.6-1.9). Accounting for co-morbidity and socio-economic status did not materially alter the findings. These data confirm that South Asian men have significantly higher CHD mortality than their European counterparts, while indicating that neither conventional risk factors, nor insulin resistance parameters or metabolic syndrome criteria as currently defined can account for this excess risk. The contribution of unmeasured factors to the elevated vascular risk in South Asians should be addressed in future studies.

Treatment and secondary prevention of ischemic coronary events in Croatia (TASPIC-CRO study)

The objective of this study is to determine the status of major risk factors for coronary heart disease in patients with established coronary heart disease in Croatia and whether the Joint European Societies' recommendations on coronary heart disease prevention are being followed in Croatia and whether secondary prevention practices have improved between 1998 and 2003. Five surveys were undertaken in 35 centres covering the geographical area of the whole of Croatia between 1 June, 1998 and 31 March, 2003. Consecutive patients of both sexes were identified after coronary-bypass grafting or a percutaneous transluminal coronary angioplasty or a hospital admission with acute myocardial infarction or ischaemia. Data collection was based on a review of medical records and the methodology used was similar to the one used in the EUROASPIRE study. Fifteen thousand, five hundred and twenty patients were enrolled (64.6% men); 35% of patients smoked cigarettes, 66% had raised blood pressure, 69% elevated serum total cholesterol, 69% elevated serum low-density lipoprotein (LDL) cholesterol, 42% low high-density lipoprotein (HDL) cholesterol, 37% elevated triglycerides, 30% diabetes and 34% family history of coronary heart disease. More men were smokers and had low HDL cholesterol, but more women had elevated total and LDL cholesterol, hypertension and diabetes. More men had Q wave acute myocardial infarction, but more women had angina. Over 5 years, the prevalence of hypercholesterolemia decreased substantially from 82.7 to 65%. Eighty-three percent of patients received aspirin and this percentage did not change during the study. The use of diuretics, calcium antagonists and nitrates did not change either. The reported use of statins, angiotensin-converting enzyme inhibitors and beta-blockers increased significantly. This survey shows a high prevalence of modifiable risk factors in Croatian patients with coronary heart disease. Although the higher use of statins, angiotensin-converting enzyme inhibitors and beta-blockers is encouraging, the fact that most coronary heart disease patients are still not achieving the recommended goals remains a concern. There is real potential to reduce the very high coronary heart disease morbidity and mortality in Croatia.

Ethnic differences in achievement of cholesterol treatment goals. Results from the National Cholesterol Education Program Evaluation Project Utilizing Novel E-Technology II.

African Americans (AA) have the highest coronary heart disease mortality rate of any ethnic group in the United States. Data from the National Cholesterol Education Program Evaluation ProjecT Utilizing Novel E-Technology (NEPTUNE) II survey were used to assess ethnic differences in low-density lipoprotein cholesterol (LDL-C) goal achievement. NEPTUNE II surveyed patients with treated dyslipidemia to assess achievement of treatment goals established by the Adult Treatment Panel III of the National Cholesterol Education Program. United States physicians working in primary care or relevant subspecialties enrolled 10 to 20 consecutive patients (May to September 2003), and patient data were recorded in Personal Digital Assistants and uploaded to a central database via the internet. Among 4,885 patients receiving treatment for dyslipidemia, 79.7% were non-Hispanic white (NHW) and 8.4% were AA. Non-Hispanic white and AA patients had significantly different frequencies of treatment success, with 69.0% and 53.7%, respectively, having achieved their LDL-C goal (P<.001). African-American patients were more likely to be in the highest risk category, and less likely to be using lipid drug therapy, taking high-efficacy statins, and receiving care from a subspecialist, but the difference in goal achievement remained significant (P<.001) after adjustment for these and other predictors of treatment success. The frequency of treatment success in dyslipidemia management was significantly lower in AA than NHW patients. Additional research is needed to elucidate reasons for this disparity and to evaluate strategies for improving goal achievement among AA patients receiving therapy for dyslipidemia.

Factors determining diagnosis and admission of Bangladeshis with coronary symptoms

Epidemiological studies show that South Asian immigrants, irrespective of any regional, cultural and religious differences, have significantly higher coronary heart disease mortality than the native white population in the UK. Evidence suggests Bangladeshi patients with acute myocardial infarction often present with atypical symptoms, which may lead to slower triage and delayed treatment. The aim of this pilot study of 18 patients is to answer the question: Does symptomatology impair the successful diagnosis and hospital admission route of Bangladeshis with coronary heart disease? This study found that Bangladeshis presenting with chest pain were less likely than white patients to offer a classical description of the pain such as ‘heaviness’ or ‘band-like’ pain.

Needs to Change the Direction of Cholesterol-related Medication—A Problem of Great Urgency

The cholesterol hypothesis implies that reducing the intake of saturated fatty acids and cholesterol and increasing that of polyunsaturated fatty acid are effective in lowering serum total cholesterol (TC), and thereby reducing the incidence of coronary heart disease (CHD). However, these dietary recommendations are essentially ineffective in reducing TC in the long run, but rather increase mortality rates from CHD and all causes. The reported "apparent relative risk of high TC in CHD mortality" (the ratio of mortality at the highest/lowest TC levels) varied several-fold among populations studied. The incidence of familial hypercholesterolemia (FH) in a population was proposed to be a critical factor in the observed variability, which could be accounted for by assuming that 1) the high CHD mortality rate in high-TC groups is mainly a reflection of the incidence and severity of FH, and 2) high TC is not a causative factor of CHD in non-FH cases. This interpretation is supported by recent observations that high TC is not positively associated with high CHD mortality rates among general populations more than 40-50 years of age. More importantly, higher TC values are associated with lower cancer and all-cause mortality rates among these populations, in which relative proportions of FH are likely to be low (circa 0.2%). Although the effectiveness of statins in preventing CHD has been accepted in Western countries, little benefit seems to result from efforts to limit dietary cholesterol intake or to TC values to less than approximately 260 mg/dl among the general population and the elderly. Instead, an unbalanced intake of omega6 over omega3 polyunsaturated fats favors the production of eicosanoids, the actions of which lead to the production of inflammatory and thrombotic lipid mediators and altered cellular signaling and gene expression, which are major risk factors for CHD, cancers, and shorter longevity. Based on the data reviewed here, it is urgent to change the direction of current cholesterol-related medication for the prevention of CHD, cancer, and all-cause mortality.