Manifestations Of Coronary Heart Disease Research Articles

The role of antihypertensive pharmacologic treatment in countering adverse pathophysiological profiles: Influence on small arteries

Usually, when antihypertensive therapy is considered in the hypertensive patient, structural cardiovascular changes are already well established and the structure of the cardiovascular system is redesigned to maintain higher than normal pressure. Left ventricular hypertrophy has been shown to be an independent risk factor for all manifestations of coronary heart disease. In hypertension, the increased pressure load over a long period of time induces degenerative changes in, for example, cerebral, renal, and coronary vessels, with well-known clinical consequences. Independent of the primary cause of hypertension, full reversal to normotension will probably occur only when the structurally reset cardiovascular system has been returned to normal dimensions by regression of structural vascular changes. In animal models severai forms of antihypertensive treatment have prevented the development of or induced regression of left ventricular hypertrophy as well as medial hypertrophy of the vessels. These effects have been related both to the extent of blood pressure reduction and to the degree of inhibition of neurohormonal trophic influences. In humans the results have been somewhat contradictory. Plethysmography has demonstrated a reduction of resistance at maximal dilatation with either combination therapy or pindolol but not with mefruside or atenolol. There may be several explanations for the difficulties in showing regression of structural vascular changes in humans: (1) inadequate treatment of high blood pressure, (2) reflexogenic activation of neurohormonal trophic factors, (3) investigation of an unsultable vascular bed, or (4) treatment started too late. The ultimate goal in the treatment of hypertension is, of course, reduction of cardiovascular morbidity and mortality, but normalization of structural cardiovascular changes is clearly the second most important therapeutic goal.

Components of hostility and the severity of coronary artery disease.

Previous research has linked various measures of hostility to the prevalence and incidence of coronary heart disease (CHD). The present study sought to determine whether some dimensions of hostility are differentially related to angiographically documented severity of coronary artery disease (CAD). Specifically, a hostility measure that correlates with indices of neuroticism was compared with a hostility measure unrelated to neurotic tendencies. For patients 60 years and younger, results were significant, revealing that neurotic hostility was inversely associated with severity of CAD whereas nonneurotic hostility scores were positively related to extent of disease. Overall hostility scores derived from the combination of the two kinds of hostility measures were unrelated to CAD severity. Results suggest that the multidimensional nature of the hostility construct should be appreciated in attempts to associate measures of hostility with manifestations of CHD.

Nonspecific electrocardiographic abnormality as a predictor of coronary heart disease: The Framingham Study

The risk of developing overt coronary heart disease is examined in relation to occurrence of nonspecific electrocardiographic S-T and T-wave abnormalities (NSA-ECG) in the Framingham Study. In the course of follow-up, 14% of the 5127 men and women had or developed NSA-ECG without clinically apparent intervening coronary heart disease. During 30 years of surveillance, 760 men and 578 women developed a first overt clinical manifestation of coronary heart disease. NSA-ECG appears to be a hallmark of a compromised coronary circulation which predicted the occurrence of every clinical manifestation of coronary heart disease independently of known risk factors including hypertension, its chief determinant. Coronary morbidity and mortality was increased twofold in each sex. The more common T-wave abnormality alone carried a significant increased risk, although the combination of S-T and T-wave seemed most hazardous. Persons who develop NSA-ECG without other explanation warrant vigorous preventive management against coronary heart disease.

Sudden cardiac death: epidemiology, causes, and mechanisms.

In the United States, more than 300,000 sudden cardiac deaths (SCD) occur each year, the most common underlying etiology of which is coronary heart disease (CHD). With increasing age, the proportion of cardiovascular causes among all natural sudden deaths increases, and the fraction of CHD deaths that are sudden decreases. The lower incidence of coronary atherosclerosis in women is reflected in their proportionately lower risk of SCD. There are no data suggesting specific hereditary factors in risk for SCD due to CHD. On an individual basis, the known risk factors for CHD cannot distinguish those at risk for SCD from those at risk for other manifestations of CHD. Pathologic studies of SCD victims have shown that extensive coronary atherosclerosis is a major marker; healed myocardial infarction is a common finding, as is myocardial hypertrophy. Nonatherosclerotic coronary artery abnormalities may be associated with SCD. Chronic congestive heart failure is a common cause of SCD. Other etiologies include inflammatory, infiltrative, neoplastic and degenerative processes, diseases of the cardiac valves, and primary electrophysiologic abnormalities. The largest group of prehospital cardiac arrest victims have ventricular fibrillation identified on initial contact, with their survival outcome being intermediate between patients with ventricular tachycardia (best outcome) and those with bradyarrhythmia or asystole (worst outcome) on initial contact.

Cholesterol and Coronary Heart Disease

SEVERAL important developments have recently given new impetus to prevention of coronary heart disease (CHD) through control of the plasma cholesterol level. Three advances have been particularly dramatic. First, the Nobel prize in medicine was awarded in 1985 to Drs Joseph Goldstein and Michael Brown for their discovery of cell-surface receptors for low-density lipoproteins (LDLs); their finding was fundamental to our understanding of how plasma cholesterol levels are controlled. Second, the Lipid Research Clinics (LRC) Coronary Primary Prevention Trial (CPPT)1reported that lowering of the plasma cholesterol level by bile acid sequestrants reduces the frequency of several manifestations of CHD, including myocardial infarction. And third, a new class of cholesterollowering drugs, namely, competitive inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A reductase, the rate-limiting enzyme in cholesterol synthesis, has been shown to markedly lower cholesterol levels.2-4Although these inhibitors are not yet approved for clinical use, they reveal the potential for

Coronary Heart Disease in Residents of Rochester, Minnesota. VII. Incidence, 1950 Through 1982

An epidemiologic study of coronary heart disease in residents of Rochester, Minnesota, has been updated through 1982. Between the time that mortality rates began to decline in the late 1960s and now, the age-adjusted incidence of all types of coronary heart disease in residents of Rochester decreased 11% in men but increased 9% in women. This difference was due mainly to changes in the incidence of myocardial infarction as the initial manifestation of coronary heart disease-in men, the rates declined by 20%, whereas the rates for women increased by 17%. The greatest changes were in the age group 50 to 69 years. From the 1965 through 1969 period to the 1979 through 1982 period, the age-adjusted incidence of sudden unexpected death as the initial manifestation of coronary heart disease decreased in both sexes, but the incidence of angina pectoris increased in both men and women. The 24-hour and 30-day case fatality rates for myocardial infarction and the incidence rates for sudden unexpected death have stabilized. Additional studies are needed to identify the reasons for the striking divergence in secular trends in coronary heart disease for men as compared with those for women.

Silent Myocardial Ischemia During Daily Activities: Studies in Asymptomatic Patients and Those with Various Forms of Angina

Asymptomatic subjects with proven coronary artery disease, including those with no previous manifestations of coronary heart disease and those with previous myocardial infarction, have silent ischemic episodes during daily activity. Patients with all forms of angina, stable effort and unstable rest angina, and those with coronary artery spasm have very frequent episodes of silent myocardial ischemia during ordinary activity. Characteristics of these episodes and evidence for these findings are reviewed.

Risk Factors for Sudden Unexpected Cardiac Death in Young Women in Rochester, Minnesota, 1960 Through 1974

A case-control study of sudden unexpected death (SUD) as the initial manifestation of coronary heart disease in women younger than 60 years of age was conducted in Rochester, Minnesota. Risk factors among the 15 SUD cases identified during the years 1960 through 1974 were compared with those in two control groups--a population group of 60 (4 age-matched controls per case) and the 59 cases of myocardial infarction diagnosed in women younger than 60 years of age in Rochester during the same period. By using Miettinen's matched analysis for comparison of SUD cases and matched controls, the relative risks for the accepted coronary heart disease risk factors of ever smoking and hypertension were 8.6 (95% confidence interval [CI], 1.3 to 57.3) and 5.7 (95% CI, 1.2 to 26.9), respectively. In a comparison of SUD cases and myocardial infarction cases by using the Mantel-Haenszel procedure and stratifying by five age groups, the odds ratios were 1.2 for ever smoking and 0.8 for hypertension. Six of the 15 SUD cases had a diagnosis of alcoholism compared with 2 of the 60 controls and 4 of the 59 myocardial infarction cases; thus, the relative risks were 12.0 (95% CI, 3.4 to 41.9) and 4.8 (95% CI, 1.3 to 18.2), respectively. Ever married SUD cases were nulliparous or had fewer children more often than the controls or the myocardial infarction cases. The combination of major psychiatric diagnosis and major tranquilizer use occurred with greater frequency among SUD cases than among controls (relative risk, 2.9; 95% CI, 0.6 to 14.1), whereas comparison of SUD cases and myocardial infarction cases for this variable resulted in a relative risk of 0.7 (95% CI, 0.3 to 1.9).

A prognostic comparison of asymptomatic left ventricular hypertrophy and unrecognized myocardial infarction: The Framingham study

In 30 years of follow-up in the Framingham study, routine biennial ECG examinations revealed 315 subjects with ECG-LVH and 164 with unrecognized ECG-MI without previous cardiac explanation. Among subjects initially free of clinically evident coronary heart disease and both ECG abnormalities, the incidence of ECG-LVH was about double that of ECG-MI. Both events exhibited a male predominance and hypertensive subjects were more vulnerable to each. In subjects with asymptomatic ECG-LVH and ECG-MI, the 10-year, age-adjusted incidence of clinical coronary heart disease was greater than the rate experienced by the general Framingham sample. Rates for ECG-LVH were almost as large as those for ECG-MI. Cardiac failure and stroke also occurred more frequently among subjects with either ECG abnormality, and rates for ECG-LVH exceeded those for ECG-MI. Death from coronary heart disease, and sudden death in particular, was also increased two- to fourfold with similar risks for ECG-LVH and ECG-MI. ECG-LVH carried a significantly greater risk than ECG-MI for cardiovascular deaths in women. These findings suggest that ECG-LVH and ECG-MI are similar subclinical events with respect to predisposing characteristics and prognosis for subsequent overt cardiovascular disease including clinical manifestations of coronary heart disease.

家族性高コレステロール血症患者長期治療によるコレステロール低下効果と冠動脈疾患の発症

We studied effects of long term treatment of four cholesterol lowering drugs; compactin, cholestylamine, probucol and niceritorol on lipid and lipoprotein concentration and on the incidence of coronary heart disease in 111 patients with familial hypercholesterolemia (FH).1. In 4 patients with homozygous FH, mean serum cholesterol levels decreased by 24 per cent with drug treatment of large dose of compactin in one patient and of 1-1.5g/day probucol in the other three patients. One patient who was suffered from myocardial infarction before treatment died of heart attack during follow-up period. Other three patients were performed AC bypass operation and their anginal attacks were controled well.2. In heterozygous patients, mean serum cholesterol levels decreased by 19 per cent. Three drugs which are known to effective for FH decreased cholesterol levels by -26±11%, -13±8% and -15±7%, resspectively. In addition, niceritorol was also effective for heterozygous FH when the sufficient doses could be given without side effect such as flashing. More than 5 per cent decrease in Achilles tendon thickness (ATT) was found in one-third patients. Although the regression of ATT required the reduction of serum cholesterol level, the reduction of ATT and that of serum cholesterol level was not closely correlated. In the patients treated with probucol, the regression of ATT was correlated with the reduction of HDL-cholesterol level.3. During follow-up period, three patients suffered of fatal or nonfatal myocardial infarction. All three patients had had manifest coronary artery disease at entry. The patients without coronary artery disease at entry did not suffered from new cardiac events during the period. Even if the patients had coronary artery disease at entry, combination therapy of surgery with hypolipidemic drugs could improve their prognosis.In conclusion, assessment of coronary arterial lesion and treatment with cholesterol-lowering drugs might be needed before the manifestation of coronary heart disease in patients with FH.

Angina Pectoris: Epidemiology and Risk Factors

Angina pectoris is of interest as a cause of disability and also because it is a marker for potential severe manifestations of coronary heart disease such as cardiac infarction or sudden death. However, the elucidation of its epidemiology is inherently difficult. It is not specific for coronary heart disease. Because it is a symptom the diagnosis cannot be validated. Clinical diagnosis is inconsistent. Standard questionnaires are more reliable but these produce different results according to minor changes in circumstances and wording. The variability of the disease means that incidence and prevalence measures are closely related to the exact method of measurement. Risk factors for angina pectoris are the same as those for coronary heart disease as a whole. The risk factors continue to predict major coronary events even when angina pectoris has developed. The angina revealed by population surveys is a much more mild, transient and less dangerous disease than that reported in clinical case series. The implication for the latter is that the results cannot be generalized unless the way in which cases are referred and selected is known.

Diabetes and Coronary Heart Disease

Clinically manifest coronary heart disease (CHD) is not uncommon in diabetics with insulin-dependent type of the disease below the age of 40, particularly when the duration of diabetes is long. Clinically manifest CHD is very common in diabetics with maturity-onset, non-insulin-dependent type of the disease, and in this type of diabetes the frequency of CHD shows little or no relation to the duration of diabetes. Premenopausal female diabetics have a clinically manifest CHD almost as often as male diabetics of the same age--a situation in sharp contrast to that in non-diabetics with large excess of CHD in males. The incidence of all manifestations of CHD (sudden and nonsudden CHD death, non-fatal myocardial infarction, "silent" myocardial infarction, and angina pectoris) is increased in diabetics as compared to non-diabetics, but the excess of CHD mortality in diabetics is especially marked, being 3 to 4 times higher than in non-diabetics. The incidence of congestive heart failure is markedly increased in diabetics and this is in part independent of increased occurrence of CHD and hypertension among diabetics. Subclinical abnormalities of left ventricular function are common in diabetics and these abnormalities appear to show some relationship to the metabolic control of diabetes and in insulin-dependent diabetics also to the presence of microangiopathy. Diabetes is associated with changes in general CHD risk factors to atherogenic direction. These changes include abnormalities in the levels and composition of plasma lipids and lipoproteins and increased frequency of hypertension. The impact of general risk factors on CHD risk appears to be similar in diabetics and non-diabetics.(ABSTRACT TRUNCATED AT 250 WORDS)

Lipids, diabetes, and coronary heart disease: Insights from the Framingham Study

Both risk factors and the incidence of cardiovascular disease are higher in diabetic patients. Total serum cholesterol has the same impact on coronary heart disease (CHD) incidence in diabetic patients as in nondiabetic individuals. Abnormal blood lipids in diabetic patients include elevated very low-density lipoproteins (VLDL) and triglyceride and reduced levels of high-density lipoproteins (HDL). These are associated with obesity and precede the onset of diabetes. Diabetes increases the risk of all clinical manifestations of CHD, has a greater impact in women, and predisposes to cardiac failure and fatal outcome. In men, it predisposes to silent myocardial infarctions. CHD risk reduction in the diabetic patient requires multifactorial control. In evaluating the lipid-induced CHD risk, the level of low-density lipoprotein (LDL) cholesterol is not as valuable as the LDL HDL cholesterol ratio, which is the most rellable criterion. Triglyceride levels make no independent contribution. Most CHD preventive measures, including weight control, exercise, avoidance of cigarettes, and improvement of glucose tolerance also increase HDL cholesterol, reduced levels of which are chiefly responsibie for the poor LDL HDL ratio in diabetics. Weight control merits a high priority because of its favorable influence on the lipid profile, glucose tolerance, and blood pressure.

Drinking and coronary heart disease: The Albany Study

The relation of alcohol consumption to coronary heart disease (CHD) was examined in a cohort of 1910 employed men aged 38 to 55 years enrolled in the Albany Study, a prospective investigation of factors related to cardiovascular disease. Two follow-up periods were examined, one between 1953–54 and 1971–72, the other after 1971–72. In the initial period, there was no clear evidence of a relation between the rate of alcohol consumption and CHD incidence. In the later period, men whose monthly consumption was 60 ounces or more had a lower than average CHD incidence rate. A negative relationship with drinking held for all manifestations of CHD. Other CHD risk factors were examined, special attention being given to cigarette smoking and HDL-cholesterol. The fact that drinking is a matter of choice may introduce some confounding factors. The absence of a relation between drinking and CHD risk in the earlier follow-up suggests the need for caution in interpreting the results.

Coronary heart disease in residents of Rochester, Minnesota. VI. Hospital and posthospital course of patients with transmural and subendocardial myocardial infarction.

During the period 1960 through 1979, 1,221 residents of Rochester, Minnesota, who were 30 years of age or older had a myocardial infarction as the first manifestation of coronary heart disease. Patients who had a prior diagnosis of congestive heart failure or valvular heart disease were excluded from this study. Of the 1,221 patients, 784 had a transmural infarction, 353 had a subendocardial infarction, and 84 had infarctions that could not be classified (most of the unclassified infarctions were associated with sudden death in patients who were not hospitalized). The age- and sex-adjusted 30-day case fatality rate was 18% among those with transmural and 9% among those with subendocardial myocardial infarction. No significant difference was found in subsequent survivorship or in net survivorship free of reinfarction during the first 5 years of follow-up. Five-year net survivorship free of reinfarction, coronary artery bypass operation, and cardiac death was not significantly different between the two groups, nor was net survivorship free of five established events (the three aforementioned events plus the development of congestive heart failure or angina). When these five events were considered independently in the two infarction cohorts, however, development of congestive heart failure was more common among patients with transmural infarction (P less than 0.01), whereas the development of angina was more common among patients with subendocardial myocardial infarction (P less than or equal to 0.06).

The stabilizing and unstabilizing influences of neurogenic and vascular activities of the heart as related to sudden cardiac death

Despite the frequency with which sudden cardiac death occurs in affluent societies, little is known about the precise mechanisms by which it is caused. Practically nothing is known about why sudden cardiac death occurs in one but not another person. It is difficult to escape the conclusion that in many instances, the final events occur almost by chance. Therefore, it would appear that every effort should be made by the physician to assist in preventing the changes, that is, cardiomegaly and myocardial ischemia, that appear to be potential markers of sudden cardiac death in many persons. Attention should be directed toward identifying and facilitating stabilizing neurogenic and vascular activities and identifying, controlling and reversing unstabilizing influences likely to foster sudden cardiac death. In the absence of a more complete knowledge of precise mechanisms, the efforts of the physician should be directed toward behavior modifications that appear to reduce the clinical manifestations of coronary heart disease which contribute to the development of cardiomegaly and myocardial ischemia.

Coronary Heart Disease in Residents of Rochester, Minnesota. V. Prognosis of Patients With Coronary Heart Disease Based on Initial Manifestation

During the period 1960 through 1979, 1,014 residents of Rochester, Minnesota, had a diagnosis of classic angina pectoris as the first manifestation of coronary heart disease, and 1,013 had a myocardial infarction as the initial manifestation. In the angina cohort, about 50% were men, and of them, 20% were 70 years old or older. The female patients were an average of 6 years older than the men, and 43% were 70 years old or older. In this cohort, the 5-year survival rate increased from 77% in the 1960s to 87% in the 1970s (P less than 0.01). The 5-year net survivorship free of a myocardial infarction increased from 76% to 85% during that same time (P less than 0.01). In the myocardial infarction cohort, the 5-year death rate among the 30-day survivors of myocardial infarction was the same during both decades of the study. The age-adjusted reinfarction rate per 100 person-years at risk during teh first 5 years of follow-up decreased very slightly among men and increased among women; thus, it remained essentially unchanged overall. Although the case fatality rate in the myocardial infarction cohort declined sharply from the 1960s to the 1970s, the long-term prognosis of the 30-day survivors of a myocardial infarction did not improve.

Familial occurrence of coronary heart disease according to clinical manifestation.

Occurrence of different clinical manifestations of coronary heart disease (CHD) was assessed among the parents and siblings of 309 men with CHD (case probands), including 103 men with fatal and 100 with nonfatal myocardial infarction (MI), and 106 men with angina pectoris (AP) and among the relatives of 106 reference men. CHD was equally common among relatives of all case probands. It was four times as common in case brothers and twice as common in case sisters as in the respective reference siblings. There were differences between the various case groups as to the predominant clinical manifestation of CHD. Cardiac deaths were commonest in the sibs of men with fatal MI, and uncomplicated angina in the men with AP. The familial resemblance in the clinical manifestations of CHD suggests familial influence in the mechanisms determining the clinical expression of the disease.

Incidence of Different Manifestations of Coronary Heart Disease in Middle‐aged Finnish Men and Women

The incidence of myocardial infarction and symptoms of coronary heart disease (CHD) were investigated in a prospective Finnish population study. Drawn from four geographical areas in Finland the study population comprised 5 438 men and 4 924 women aged 30-59 at entry. The results are based on a re-examination of the study population after a mean follow-up time of six years. The average annual incidence of coronary death was 3.8/1 000, and that of non-fatal infarction 6.5/1 000 in men and 0.4/1 000 and 2.1/1 000 in women. Ten per cent of all infarctions were silent, revealed only by ECG changes. Cases of new angina pectoris comprised 40% of all the new events in men but 80% in women. This descriptive report serves as the basis for subsequent analyses comprising risk factors for different CHD manifestations.

Reproductive history in women with coronary heart disease. A case-control study.

Reproductive history events may be risk factors for coronary heart disease among women under age 60. In this study, the cases were 169 women under age 60 with a diagnosis of coronary heart disease while residents of Rochester, Minnesota. The first manifestation of coronary heart disease was angina in 95, myocardial infarction in 59, and sudden unexpected death in 15 women. Two age- and sex-matched controls for each case were selected from all registrations for care at the Mayo Clinic in the same year the case was diagnosed. The cases had more of the accepted coronary heart disease risk factors--i.e., hypertension (relative risk = 2.9), smoking (relative risk = 2.4), elevated serum cholesterol (relative risk = 2.6), and diabetes (relative risk = 4.1)--than did controls. In addition, women undergoing artificial menopause and those whose first pregnancy was before age 25 appeared to be at higher risk of coronary heart disease. Use of multivariate analysis to control for known coronary heart disease risk factors resulted in a relative risk of 1.9 for women whose age at first pregnancy was less than 20, and 1.8 for those whose age at first pregnancy was 20-24, as compared with those never pregnant and those whose age at first pregnancy was greater than or equal to 25.