Increase In Coronary Heart Disease Mortality Research Articles

Explaining the Decline in Coronary Heart Disease Mortality Rate Using IMPACT Model: Estimation of the Changes in Risk Factors and Treatment Uptake in Iran between 2007 and 2016.

Coronary heart disease (CHD) contributes significantly to mortality and morbidity in Iran. A model was fitted in this study to determine changes in risk factors and treatment uptake to CHD mortality rate reduction in Isfahan between 2007 and 2016. The IMPACT model was fitted to determine how much the decrease in CHD death can be explained by treatment uptake and significant risk factors included in the analyses for adults aged 35 to 84 years. Body mass index (BMI), diabetes, and smoking were considered as the CHD risk factors in the model. Medical and interventional treatments were studied in four different groups of patients. The primary data sources were obtained from the Persian registry of cardiovascular disease (PROVE), The Isfahan healthy heart program (IHHP), and the impact of self-care management and adopted Iranian guidelines for hypertension treatment on improving the control rate of hypertension (IMPROVE CARE) study, death registration system, and the Isfahan province Cemetery. The CHD mortality rate decreased by 14% between 2007 and 2016 in Iran for adults aged 35 to 84 years and prevented or delayed 212 CHD deaths in 2016. Treatment uptakes caused 99% postponed or prevented death. Treatment for heart failure in hospitals explained approximately half of the death prevented by treatment. Risk factors caused about 15% of excess death. It appears that the prevalence of CHD is increasing while the death rate is decreasing because of these observed changes. Risk factors worsened in 2016 and, without treatment, could lead to an increase in CHD mortality in Iran. Preventive policies should control the risk factor and contribute to the decrease in CHD death.

Explaining the increment in coronary heart disease mortality in Mexico between 2000 and 2012.

Mexico is still in the growing phase of the epidemic of coronary heart disease (CHD), with mortality increasing by 48% since 1980. However, no studies have analyzed the drivers of these trends. We aimed to model CHD deaths between 2000 and 2012 in Mexico and to quantify the proportion of the mortality change attributable to advances in medical treatments and to changes in population-wide cardiovascular risk factors. We performed a retrospective analysis using the previously validated IMPACT model to explain observed changes in CHD mortality in Mexican adults. The model integrates nationwide data at two-time points (2000 and 2012) to quantify the effects on CHD mortality attributable to changes in risk factors and therapeutic trends. From 2000 to 2012, CHD mortality rates increased by 33.8% in men and by 22.8% in women. The IMPACT model explained 71% of the CHD mortality increase. Most of the mortality increases could be attributed to increases in population risk factors, such as diabetes (43%), physical inactivity (28%) and total cholesterol (24%). Improvements in medical and surgical treatments together prevented or postponed 40.3% of deaths; 10% was attributable to improvements in secondary prevention treatments following MI, while 5.3% to community heart failure treatments. CHD mortality in Mexico is increasing due to adverse trends in major risk factors and suboptimal use of CHD treatments. Population-level interventions to reduce CHD risk factors are urgently needed, along with increased access and equitable distribution of therapies.

Abstract P205: Meat Intake and Risk of Coronary Heart Disease Mortality in Singapore Chinese Adults

Introduction: Epidemiological studies have reported inconsistent association between meat intake and coronary heart disease (CHD) mortality. We aimed to evaluate this association in a Chinese population with high fish intake and consumption of pork as red meat. Hypothesis: We assessed the hypothesis that intake of red meat, poultry, and fish/shellfish is associated with CHD mortality risk in an Asian population. Methods: The Singapore Chinese Health Study is a population-based cohort that recruited 63,257 Chinese adults aged 45-74 years from 1993 to 1998 in Singapore. A validated 165-item semi-quantitative food-frequency questionnaire was used to assess usual diet at recruitment, and mortality information was identified via registry linkage up to December 31, 2014. Cox proportional hazard models were used to calculate HRs (95% CI) with adjustment for potential confounders in 60,298 eligible participants free of self-reported CHD and stroke at baseline. Results: Median intake of total meat in this population was 95.9 g/d (interquartile range: 66.5-133), averagely comprised of 27.9% red meat, 18.3% poultry, and 53.6% fish/shellfish.During 981,983 person-years of follow-up, we identified 2,610 CHD deaths among 57,078 subjects who were free of cardiovascular disease at baseline. After controlling for socio-demographic, lifestyle and dietary factors including intakes of poultry and fish/shellfish, red meat intake was associated with increased CHD mortality risk (HR comparing highest vs. lowest quartiles 1.17; 95% CI 1.04-1.32; P-trend=0.005), which became insignificant after adjusting for cholesterol intake (1.11; 0.97-1.26; P-trend=0.11). Conversely, an inverse association was observed for poultry intake (0.88; 0.78-0.99; P-trend=0.03) which remained significant when adjusted for dietary cholesterol (0.85; 0.75-0.96; P-trend=0.007). Fish/shellfish intake was marginally associated with decreased risk of CHD mortality after adjusting for cholesterol (0.91; 0.80-1.03; P-trend=0.045). Dietary cholesterol was associated with an increased risk even after adjusting for intake of red meat, poultry, and fish/shellfish (1.22; 1.07-1.39; P-trend=0.002) or dietary saturated fatty acids, monounsaturated fatty acids, n-3, and n-6 (1.23; 1.07-1.42; P-trend=0.003). Conclusions: In this large cohort study of Chinese adults, red meat intake was associated with a higher risk of CHD mortality that was partly mediated by its cholesterol content. Conversely, poultry was related to a lower risk of CHD mortality.

Prognostic Significance of Premature Ventricular Contractions without Obvious Heart Diseases Determined by Standard 12-Lead Electrocardiography Considering their Morphology.

Although ventricular premature contraction (VPC) commonly arises in subjects with and without heart diseases, the prognosis of VPC has remained controversial and the effect of their morphology on mortality has not been fully determined in subjects without obvious heart diseases. The objective of this study was to assess the morphologic effect of VPC on mortality. Japanese atomic bomb survivors (n = 6685) underwent baseline health examinations and standard 12-lead electrocardiogram (ECG) between January 1990 and December 1991. Of these, we extracted data from 5,685 (67.1% women) subjects who had neither heart diseases nor electrocardiographic abnormalities at baseline. Among them, we identified 131 VPC cases using standard 12-lead ECG and classified them into left bundle branch block (LBBB) type (n = 74), right bundle branch block (RBBB) type (n = 21), and undetermined type (n = 36) according to their morphology. These subjects were followed up until December 2008; we compared all-cause, cardiac and coronary heart disease (CHD) mortality rates using multivariate Cox regression analysis between those with and without VPC. No VPCs were associated with all-cause and cardiac mortality, but the LBBB type was significantly associated with CHD mortality (hazard ratio, 2.73; 95% confidence interval, 1.11-6.73) after controlling for age, sex, smoking status, alcohol consumption, and underlying diseases. Among Japanese atomic bomb survivors without obvious heart diseases, LBBB-type VPC was associated with increased CHD mortality. Larger studies are needed to confirm the effect of morphology as it might help to predict the risk.

T-wave inversion and mortality risk

Objective. To investigate the predictive value of T-wave inversion (TWI) on routine electrocardiogram (ECG) for mortality in the general population with various risk groups in a prospective population-based follow-up study.Subjects. ECGs of a random population-based sample of 1814 men aged 42–60 years without coronary heart disease (CHD) at baseline.Results. During an average follow-up of 21 years, 685 deaths occurred. Of these deaths 174 were due to CHD and 278 to cardiovascular disease (CVD). There were 57 subjects with TWI. After adjusting for age, TWI was associated with an increased CHD mortality (relative risk (RR) 4.10, 95% CI 2.26–7.41), CVD mortality (RR 3.47, 95% CI 2.09–5.78), and all-cause mortality (RR 2.07, 95% CI 1.37–3.12). After further adjustment for conventional risk factors, TWI remained statistically significant, predicting CHD mortality (RR 2.62, 95% CI 1.57–4.36), CVD mortality (RR 2.18, 95% CI 1.40–3.38), and all-cause mortality (RR 1.41, 95% CI 1.00–2.01), respectively.Conclusion. TWI is a strong predictor for CHD, CVD, and all-cause mortality in the general population. The respective risks of CHD and CVD among men with TWI were also increased among men with high blood pressure, LDL cholesterol, and obesity.

Redistribution of heart failure as the cause of death: the Atherosclerosis Risk in Communities Study

BackgroundHeart failure is sometimes incorrectly listed as the underlying cause of death (UCD) on death certificates, thus compromising the accuracy and comparability of mortality statistics. Statistical redistribution of the UCD has been used to examine the effect of misclassification of the UCD attributed to heart failure, but sex- and race-specific redistribution of deaths on coronary heart disease (CHD) mortality in the United States has not been examined.MethodsWe used coarsened exact matching to infer the UCD of vital records with heart failure as the UCD from 1999 to 2010 for decedents 55 years old and older from states encompassing regions under surveillance by the Atherosclerosis Risk in Communities (ARIC) Study (Maryland, Minnesota, Mississippi, and North Carolina). Records with heart failure as the UCD were matched on decedent characteristics (five-year age groups, sex, race, education, year of death, and state) to records with heart failure listed among the multiple causes of death. Each heart failure death was then redistributed to plausible UCDs proportional to the frequency among matched records.ResultsAfter redistribution the proportion of deaths increased for CHD, chronic obstructive pulmonary disease, diabetes, hypertensive heart disease, and cardiomyopathy, P < 0.001. The percent increase in CHD mortality after redistribution was the highest in Mississippi (12%) and lowest in Maryland (1.6%), with variations by year, race, and sex. Redistribution proportions for CHD were similar to CHD death classification by a panel of expert reviewers in the ARIC study.ConclusionsRedistribution of ill-defined UCD would improve the accuracy and comparability of mortality statistics used to allocate public health resources and monitor mortality trends.

Abstract P365: Turning in the Mortality Trends from Coronary Heart Disease in Japan: Age-Specific Analysis of the Regional Difference in Japan from 1969 to 2007

Objective: To examine the recent mortality trends of coronary heart disease (CHD), we compared the age specific CHD mortality trends in Japan and in urban and in the rest of Japan, respectively using Vital Statistics. Methods and Results: We compared CHD mortality rates in all Japan, the urban population (20 million) and in the rest of Japan (100 million) from 1969 to 2007 for 30 to 69 years of age. In 1969 [[Unable to Display Character: &amp;#8209;]] 1970, the age[[Unable to Display Character: &amp;#8209;]]adjusted CHD mortality rate was 57.7 per 100,000 for men and 25.9 for women in Japan, and was the same as those of the urban population (59.2 for men and 26.8 for women) and the rest of Japan (57.3 for men and 25.9 for women). The CHD mortality rate in the rest of Japan decreased to 28.4 for men and 7.6 for women in 2006-2007. Although CHD mortality rate in the urban population also decreased to 39.9 for men and 10.1 for women in 2006 - 2007, the decline was much smaller. Trends in age-specific CHD mortality rates was compared between Period I (1969 - 1978), Period II (1981- 1994) and period III (1996 - 2007). Among men in Japan and in the rest of Japan, the decline in the mortality rate for the 30 to 49[[Unable to Display Character: &amp;#8209;]]year[[Unable to Display Character: &amp;#8209;]]old[[Unable to Display Character: &amp;#8209;]]age group was initially observed in Period I and II, and has turned to increase significantly (p&lt;0.001) in the Period III while continuous declining trends in 50-59 and 60-69 year old-age-group. Trends in urban population went ahead, changes in the declining trends was observed both the Period II and III among 30-49 year-old-age group and period III among 50-59 year-old-age group while continuous decline was observed among 60-69 year-old-age group. Similar trends were observed among women. These trends coincide with the increase in the fat intake mainly among younger generation. Conclusions: Observed increase in CHD mortality of men in Japan among younger generation proceeded by those in the urban population may predict the future increase in CHD mortality in Japan.

Coronary heart disease in Indian Asians

The Indian Asian population accounts for a fifth of all global deaths from coronary heart disease (CHD). CHD deaths on the Indian subcontinent have doubled since 1990, and are predicted to rise a further 50% by 2030. Reasons underlying the increased CHD mortality among Indian Asians remain unknown. Although conventional cardiovascular risk factors contribute to CHD in Indian Asians as in other populations, these do not account for their increased risk. Type-2 diabetes, insulin resistance and related metabolic disturbances are more prevalent amongst Indian Asians than Europeans, and have been proposed as major determinants of higher CHD risk among Indian Asians. However, this view is not supported by prospective data. Genome-wide association studies have not identified differences in allele frequencies or effect sizes in known loci to explain the increased CHD risk in Indian Asians. Limited knowledge of mechanisms underlying higher CHD risk amongst Indian Asians presents a major obstacle to reducing the burden of CHD in this population. Systems biology approaches such as genomics, epigenomics, metabolomics and transcriptomics, provide a non-biased approach for discovery of novel biomarkers and disease pathways underlying CHD. Incorporation of these ‘omic’ approaches in prospective Indian Asian cohorts such as the London Life Sciences Population Study (LOLIPOP) provide an exciting opportunity for the identification of new risk factors underlying CHD in this high risk population.

Trends in age-specific coronary heart disease mortality in the European Union over three decades: 1980–2009

AimsRecent decades have seen very large declines in coronary heart disease (CHD) mortality across most of Europe, partly due to declines in risk factors such as smoking. Cardiovascular diseases (predominantly CHD and stroke), remain, however, the main cause of death in most European countries, and many risk factors for CHD, particularly obesity, have been increasing substantially over the same period. It is hypothesized that observed reductions in CHD mortality have occurred largely within older age groups, and that rates in younger groups may be plateauing or increasing as the gains from reduced smoking rates are increasingly cancelled out by increasing rates of obesity and diabetes. The aim of this study was to examine sex-specific trends in CHD mortality between 1980 and 2009 in the European Union (EU) and compare trends between adult age groups.MethodsSex-specific data from the WHO global mortality database were analysed using the joinpoint software to examine trends and significant changes in trends in age-standardized mortality rates. Specific age groups analysed were: under 45, 45–54, 55–64, and 65 years and over. The number and location of significant joinpoints for each country by sex and age group was determined (maximum of 3) using a log-linear model, and the annual percentage change within each segment calculated. Average annual percentage change overall (1980–2009) and separately for each decade were calculated with respect to the underlying joinpoint model.ResultsRecent CHD rates are now less than half what they were in the early 1980s in many countries, in younger adult age groups as well as in the population overall. Trends in mortality rates vary markedly between EU countries, but less so between age groups and sexes within countries. Fifteen countries showed evidence of a recent plateauing of trends in at least one age group for men, as did 12 countries for women. This did not, however, appear to be any more common in younger age groups compared with older adults. There was little evidence to support the hypothesis that mortality rates have recently begun to plateau in younger age groups in the EU as a whole, although such plateaus and even a small number of increases in CHD mortality in younger subpopulations were observed in a minority of countries.ConclusionThere is limited evidence to support the hypothesis that CHD mortality rates in younger age groups in the member states of the EU have been more likely to plateau than in older age groups. There are, however, substantial and persistent inequalities between countries. It remains vitally important for the whole EU to monitor and work towards reducing preventable risk factors for CHD and other chronic conditions to promote wellbeing and equity across the region.

Explaining the increase in coronary heart disease mortality in Syria between 1996 and 2006

BackgroundDespite advances made in treating coronary heart disease (CHD), mortality due to CHD in Syria has been increasing for the past two decades. This study aims to assess CHD mortality trends in Syria between 1996 and 2006 and to investigate the main factors associated with them.MethodsThe IMPACT model was used to analyze CHD mortality trends in Syria based on numbers of CHD patients, utilization of specific treatments, trends in major cardiovascular risk factors in apparently healthy persons and CHD patients. Data sources for the IMPACT model included official statistics, published and unpublished surveys, data from neighboring countries, expert opinions, and randomized trials and meta-analyses.ResultsBetween 1996 and 2006, CHD mortality rate in Syria increased by 64%, which translates into 6370 excess CHD deaths in 2006 as compared to the number expected had the 1996 baseline rate held constant. Using the IMPACT model, it was estimated that increases in cardiovascular risk factors could explain approximately 5140 (81%) of the CHD deaths, while some 2145 deaths were prevented or postponed by medical and surgical treatments for CHD.ConclusionMost of the recent increase in CHD mortality in Syria is attributable to increases in major cardiovascular risk factors. Treatments for CHD were able to prevent about a quarter of excess CHD deaths, despite suboptimal implementation. These findings stress the importance of population-based primary prevention strategies targeting major risk factors for CHD, as well as policies aimed at improving access and adherence to modern treatments of CHD.

Association of Long-term Exposure to Community Noise and Traffic-related Air Pollution With Coronary Heart Disease Mortality

In metropolitan areas, road traffic is a major contributor to ambient air pollution and the dominant source of community noise. The authors investigated the independent and joint influences of community noise and traffic-related air pollution on risk of coronary heart disease (CHD) mortality in a population-based cohort study with a 5-year exposure period (January 1994-December 1998) and a 4-year follow-up period (January 1999-December 2002). Individuals who were 45-85 years of age and resided in metropolitan Vancouver, Canada, during the exposure period and did not have known CHD at baseline were included (n = 445,868). Individual exposures to community noise and traffic-related air pollutants, including black carbon, particulate matter less than or equal to 2.5 μm in aerodynamic diameter, nitrogen dioxide, and nitric oxide, were estimated at each person's residence using a noise prediction model and land-use regression models, respectively. CHD deaths were identified from the provincial death registration database. After adjustment for potential confounders, including traffic-related air pollutants or noise, elevations in noise and black carbon equal to the interquartile ranges were associated with 6% (95% confidence interval: 1, 11) and 4% (95% confidence interval: 1, 8) increases, respectively, in CHD mortality. Subjects in the highest noise decile had a 22% (95% confidence interval: 4, 43) increase in CHD mortality compared with persons in the lowest decile. These findings suggest that there are independent effects of traffic-related noise and air pollution on CHD mortality.

Association of coronary heart disease mortality with risk factors according to length of follow-up and serum cholesterol level in men: the Oslo Study cohort

We aimed to clarify the strength of the association between conventional and metabolic risk factors to coronary heart disease (CHD) mortality across short, intermediate, and long periods of follow-up and whether the effects of risk factors are heterogeneous across serum cholesterol levels. The Oslo Study prospective cohort of 14,846 men aged 40-49 years was followed from screening in 1972-73 until 2006, during which time 1655 subjects died of CHD. Multivariate-adjusted Cox proportional models compared hazard ratios (HRs) and 95% confidence intervals (CIs) for CHD mortality across 0-12, 12-24, and 24-33 years of follow-up. Interactions between risk factors and quartile level of total serum cholesterol were assessed. Total cholesterol, blood pressure, and cigarette smoking were associated with CHD mortality in multivariate analyses across all follow-up periods. Nonfasting triglyceride levels were associated with CHD in multivariate analyses (0-12 years, HR 1.12, 95% CI 1.00-1.25; 12-24 years, HR 1.13, 95% CI 1.04-1.23; 24-33 years, HR 1.09, 95% CI 1.00-1.19; 0-33 years, HR 1.10, 95% CI 1.05-1.16). A metabolic risk factor score (based on blood pressure, triglycerides, body mass index, and glucose) retained predictivity across all periods. The relations between systolic blood pressure, triglycerides, and metabolic risk factor score to CHD were stronger in the lower than the upper quartiles of serum cholesterol (p < 0.001). Conventional risk factors and nonfasting triglycerides increased CHD mortality across all periods of follow-up. The association with metabolic variables was strongest in men with low total cholesterol levels supporting the idea that lowering cholesterol should be the primary target of primary prevention.

Late-life coronary heart disease mortality of Finnish war veterans in the TAMRISK study, a 28-year follow-up

BackgroundWartime stress has been associated with increased late-life mortality of all causes of death. We evaluated whether wounded Finnish World War II veterans who were alive at the age of 55 have increased long-term coronary heart disease (CHD) mortality.MethodsHealth survey data were recorded in 1980 from 667 men, aged 55 years. Of them 102 had been wounded or injured in action during 1939-1945. The remaining participants served as the comparison group. The death certificates during a 28-year follow-up were obtained from the national statistics centre. Statistical comparisons were done by Cox proportional hazard regression model.ResultsThere were altogether 140 deaths from CHD. In men who had been wounded or injured in action the crude CHD mortality rate per 10,000 population was 2843, while in the comparison group the corresponding figure was 1961. Men who had been wounded or injured in action were 1.7 times (95% CI 1.1-2.5; p = 0.01) more likely to die from CHD than the comparison group.ConclusionsPhysical trauma at young adulthood may extend to lifelong effects on health. This study suggests that being physically wounded or injured in war may lead to increased CHD mortality in late adulthood in a Finnish population.

Long-Term Exposure to Traffic-Related Air Pollution and the Risk of Coronary Heart Disease Hospitalization and Mortality

BackgroundEpidemiologic studies have demonstrated that exposure to road traffic is associated with adverse cardiovascular outcomes.ObjectivesWe aimed to identify specific traffic-related air pollutants that are associated with the risk of coronary heart disease (CHD) morbidity and mortality to support evidence-based environmental policy making.MethodsThis population-based cohort study included a 5-year exposure period and a 4-year follow-up period. All residents 45–85 years of age who resided in Metropolitan Vancouver during the exposure period and without known CHD at baseline were included in this study (n = 452,735). Individual exposures to traffic-related air pollutants including black carbon, fine particles [aerodynamic diameter ≤ 2.5 μm (PM2.5)], nitrogen dioxide (NO2), and nitric oxide were estimated at residences of the subjects using land-use regression models and integrating changes in residences during the exposure period. CHD hospitalizations and deaths during the follow-up period were identified from provincial hospitalization and death registration records.ResultsAn interquartile range elevation in the average concentration of black carbon (0.94 × 10−5/m filter absorbance, equivalent to approximately 0.8 μg/m3 elemental carbon) was associated with a 3% increase in CHD hospitalization (95% confidence interval, 1–5%) and a 6% increase in CHD mortality (3–9%) after adjusting for age, sex, preexisting comorbidity, neighborhood socioeconomic status, and copollutants (PM2.5 and NO2). There were clear linear exposure–response relationships between black carbon and coronary events.ConclusionsLong-term exposure to traffic-related fine particulate air pollution, indicated by black carbon, may partly explain the observed associations between exposure to road traffic and adverse cardiovascular outcomes.

Hematocrit and the risk of coronary heart disease mortality in the TAMRISK study, a 28-year follow-up

Objective To evaluate whether hematocrit (HCT) is associated with coronary heart disease (CHD) mortality in men over 55 years of age in Finland. Methods Health survey data were recorded in 1980 from 670 men, aged 55 years. The causes of deaths during a 28-year follow-up were obtained from official records. Statistical comparisons were done by Cox proportional hazard regression model after dividing the men into two groups, one with HCT < 50% and the other, HCT ≥ 50%. Results There were altogether 412 deaths of all causes, including 140 from CHD. In men having HCT < 50%, the crude CHD mortality rate per 10,000 population was 2203, while in men with HCT ≥ 50%, the corresponding figure was 4255. Men with HCT ≥ 50% were 2.4 times (95% CI 1.6–3.5) more likely to die from CHD than were men with HCT < 50%. After adjusting for established coronary risk factors, the increased risk remained 1.8-fold (95 % CI, 1.1–2.7). Conclusions Borderline polycythemia was associated with increased CHD mortality. The cut-off value in our study was ≥ 50%, proposing that for men over 55 years of age such HCT levels might be an additional risk factor.

Diurnal Temperature Range is a Risk Factor for Coronary Heart Disease Death

BackgroundAlthough the relation between day-to-day temperature change and coronary heart disease (CHD) mortality is well established, it is unknown whether temperature variation within 1 day, ie, diurnal temperature range (DTR), is an independent risk factor for acute CHD death.MethodsWe used time-series and case-crossover approaches to assess the relation between DTR and daily CHD mortality between 2001 and 2004 in Shanghai, China. Specifically, we used exposures averaged over periods varying from 1 to 5 days to assess the effects of DTR on CHD mortality. We estimated the percent increase in the number of daily deaths related to CHD that were associated with DTR, after adjustment for daily meteorologic conditions (temperature and relative humidity) and levels of outdoor air pollutants.ResultsBoth time-series and case-crossover analyses showed that DTR was significantly associated with the number of daily deaths related to CHD. A 1 °C increase in 2-day lagged DTR corresponded to a 2.46% (95% CI, 1.76% to 3.16%) increase in CHD mortality on time-series analysis, a 3.21% (95% CI, 2.23% to 4.19%) increase on unidirectional case-crossover analysis, and a 2.13% (95% CI, 1.04% to 3.22%) increase on bidirectional case-crossover analysis.ConclusionsOur findings suggest that DTR is an independent risk factor for acute CHD death.

Retinopathy predicts coronary heart disease mortality

Background: Retinopathy lesions are fairly common findings in clinic settings and may predict risk of coronary heart disease (CHD). Objective: To examine whether retinopathy independently predicts a risk of CHD-related...

Bodies at Risk. An Ethnography of Heart Disease– by Wheatley, E. E.

Wheatley, E. E. Bodies at Risk. An Ethnography of Heart Disease . 2006 Aldershot : Ashgate . 148pp £45.00 ISBN 0754643077 (hbk) Cardiovascular diseases are the main causes of death in the modern world, with 17 million deaths annually according to the World Health Organisation. Of these, some 7 million result from coronary heart disease (CHD), largely as a result of acute myocardial infarction. While deaths appear to be falling (a welcome trend seen in the UK and elsewhere in recent decades), the global burden of CHD is increasing as a result of lifestyle changes, increasing urbanisation, and longer life expectancy. An estimated 83 per cent of future increases in CHD mortality will be seen in developing countries. The impact of CHD on individuals has been well explored and there is an abundant literature in the biomedical press. This book examines the experiences of having heart disease with no exclusion criteria: people qualified as participants if they had a cardiac condition irrespective of age, gender, or co-morbidities. The author worked in a heart centre in a voluntary capacity and met patients at various stages of their ‘cardiac journey’, complemented by periods of internship in cardiac rehabilitation clinics. Observational data were combined with findings from formal interviews undertaken both in the acute setting and following discharge from hospital. Throughout its six chapters the book provides insights into how patients managed the bodily and emotional sequelae of heart disease, exploring the concept of an individual ‘reskilling’ as a form of coping, and how this is a continuous process in the struggle to reclaim what may have been lost after an acute event. Social negotiations and interactional dilemmas, alongside physical efforts, are seen as central to recovery. Study participants understood the importance of taking measures (such as physical exercise and smoking cessation) to reducing the risk of a further heart attack but most (in the author's word) ‘fell short’ in one way or another in their efforts. While eliminating risk was not entirely possible, ongoing negotiation helped most at least to come to terms with the changes required. Market-based rehabilitation services were seen to individualise disease prevention and fitness efforts, but messages about risk were not consistent and coherent but rather contradictory and shifting. Advice from health professionals for patients simply to ‘manage’ stress, however well-intentioned, were seen as insufficient, and more socially progressive approaches were required. Styles of reskilling, from an ‘ethic of exactitude’ through resignation, playfulness, evasion, objection to experimentation, are discussed: patients tended to move between these categories over the course of their illness, and were enabled rather than repressed by clinical routines and regimens. Rehabilitation has emerged as a profitable enterprise in the United States, expanding to provide for those ‘at risk’ as well as those who have suffered an acute event. Although I am unfamiliar with the methodology used in the research and much of the literature cited (I work principally within a biomedical model) I found this an interesting and stimulating read, and there was much in the transcripts of patient experiences that rings true both from personal observation as a practitioner and from the UK literature on recovery from bypass surgery, for example. Health care in the United States is of course very different from that provided by our much criticised (but actually highly rated and much more equitable) NHS, but there are important insights here for those planning, commissioning and delivering cardiac rehabilitation services in the era of choice and responsiveness. This book would be of value not just to the academic but to the cardiac rehabilitation team.

South Asians and Cardiovascular Risk

Case presentation: A 36-year-old nonsmoking, normotensive South Asian man presented to the emergency department of a community hospital with retrosternal chest pain of &60 minutes’ duration. His 12-lead ECG demonstrated 10 mm of ST-segment elevation in leads V2 through V6, and he received fibrinolytic therapy within 90 minutes of symptom onset. His pain resolved, but his ST segments only partially normalized; he had a peak creatine kinase of 4564 IU/L, and he showed signs of early heart failure. LDL cholesterol was 135 mg/dL, HDL 32 mg/dL, triglycerides 20 mg/dL, and total cholesterol 206 mg/dL; his body mass index (BMI) was 24 kg/m2. Cardiac catheterization demonstrated severe and diffuse triple-vessel disease, including occlusion of the proximal left anterior descending artery, as well as moderate left ventricular dysfunction. While in the hospital, he was diagnosed with new-onset type 2 diabetes mellitus and subsequently underwent uncomplicated coronary bypass surgery. South Asians are individuals whose ethnic roots originate from the Indian subcontinent, a large geographic area that includes India, Pakistan, Sri Lanka, Nepal, and Bangladesh. Collectively, South Asians represent one fifth of the global population. In North America, more than 2 million South Asians reside in the United States and almost 1 million in Canada. It is important to recognize that the term “South Asian” refers to a heterogeneous population, with important differences in diet, culture, and lifestyle among different South Asian populations and religions. Multiple studies of migrant South Asian populations have, however, confirmed a 3- to 5-fold increase in the risk for myocardial infarction and cardiovascular death as compared with other ethnic groups.1–3 In an analysis of age-standardized coronary heart disease (CHD) mortality in Canada over a 15-year period, South Asians had the highest CHD mortality compared with individuals of Chinese and European descent.4 In …

Albuminuria and incident coronary heart disease in Australian Aboriginal people

It has been suggested that albuminuria is useful in identifying persons at increased risk of coronary heart disease (CHD). Australian Aborigines have exceedingly high rates of renal failure together with increased CHD mortality. We undertook this prospective cohort study to assess the independent effect of albuminuria on CHD risk in Aboriginal people in the Northern Territory of Australia. We examined the relation between micro- and macroalbuminuria and incident CHD in a sample of 870 Aboriginal adults aged 20 to 74 years old without prevalent baseline CHD. Cox proportional hazards models were used to assess the association between baseline albuminuria and CHD incidence. During a median of 9.2 years of follow-up, 89 CHD events occurred during the follow-up period (1992 to 2003). The incidence of CHD increased significantly across categories of albuminuria (4.4, 10.9, and 29.8 per 1000 person-years for normoalbuminuria, microalbuminuria, and macroalbuminuria, respectively). The multiple Cox proportional hazards regression showed the hazard ratio was 3.4 (95% CI 1.6, 7.3), adjusting for age, gender, body mass index (BMI), blood pressure, total cholesterol, diabetes status, cigarette smoking, and alcohol consumption, for macroalbuminuria group. Hazard ratio for microalbuminuria group was not significantly different from unity during the first 6 years of follow-up but significantly higher during the follow-up period > or = 6 years with adjusted hazard ratio 9.0 (95% CI 2.0, 40.0). Independent of traditional cardiovascular risk factors, both microalbuminuria and macroalbuminuria may be useful in identifying persons at increased risk of CHD in Aboriginal people.