Prior History Of Coronary Heart Disease Research Articles

Temporal trends in coronary heart disease mortality and sudden cardiac death from 1950 to 1999: the Framingham Heart Study.

Throughout the past 50 years, heart disease has been the leading cause of death in the United States. Although declines in coronary heart disease (CHD) mortality have been noted, there is still uncertainty about the magnitude of the decline and whether the trend is similar for sudden cardiac death (SCD). We examined temporal trends in SCD and nonsudden CHD death in the Framingham Heart Study original and offspring cohorts from 1950 to 1999. SCD was defined as a death attributed to CHD with preceding symptoms that lasted less than 1 hour; all deaths were adjudicated by a physician panel. Log-linear Poisson regression was used to estimate CHD mortality and SCD risk ratios (RRs); RRs were adjusted for age and gender. There were 811 CHD deaths: 453 nonsudden and 358 SCDs. Ninety-one (20%) of nonsudden CHD deaths and 173 (48%) of SCDs were in subjects free of antecedent CHD. From 1950-1969 to 1990-1999, overall CHD death rates decreased by 59% (95% CI 47% to 68%, P(trend)<0.001). Nonsudden CHD death decreased by 64% (95% CI 50% to 74%, P(trend)<0.001), and SCD rates decreased by 49% (95% CI 28% to 64%, P(trend)<0.001). These trends were seen in men and women, in subjects with and without a prior history of CHD, and in smokers and nonsmokers. The risks of SCD and nonsudden CHD mortality have decreased by 49% to 64% over the past 50 years. These trends were evident in subjects with and without heart disease, which suggests important contributions of primary and secondary prevention to the decreasing risk of CHD death and SCD.

Anthropometric predictors of coronary heart disease in Chinese women.

To evaluate the associations of body size and fat distribution with incidence of coronary heart disease (CHD) in Chinese women. Population-based, prospective cohort study. A total of 67 334 women aged 40-70 y, who had no prior history of CHD, stroke, and cancer at study recruitment. Weight, standing and sitting heights, circumferences of waist and hip, and ratios of the anthropometric measurements. incidence of CHD (non-fatal myocardial infarction (MI) or fatal CHD). After a mean follow-up of 2.5 y (168 164 person-years), there were 70 incident cases of CHD (49 non-fatal MIs and 21 CHD deaths). Body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), waist-to-standing height ratio (WHtR), waist-to-sitting height ratio (WsHtR), and conicity index were all positively associated with the risk of CHD. With the exception of WHR, all other anthropometric indexes only predicted the risk of CHD among women </=55 y of age at enrollment. The relative risks (RRs) between extreme tertiles of BMI were 9.0 (95% CI, 2.0-41.5; P for trend=0.002) for younger women vs 1.3 (0.6-3.0; P for trend=0.83) for older women. Similarly, the RRs for WC, WHtR, WsHtR, and conicity index were 6.1 (1.8-21.4) vs 1.9 (0.6-5.4), 9.4 (2.6-33.8) vs 1.2 (0.5-3.1), 15.2 (3.3-69.1) vs 1.0 (0.4-2.5), and 7.8 (2.2-28.0) vs 0.9 (0.4-2.3) for the young and elderly, respectively. In contrast, the RR for WHR was 3.2 (1.1-9.1) for the young and 2.9 (1.0-8.4) for the elderly. WHR was positively associated with the risk of CHD in both younger and older women, while other anthropometrics, including BMI, were related to CHD risk primarily among younger women.

Diabetes and vascular disease: common links in the emerging epidemic of coronary artery disease

Although diabetes mellitus (DM) is primarily a metabolic disorder, it is also a vascular disease. Most patients with diabetes die from cardiovascular disease (CVD). Several lines of available evidence suggest that cardiovascular complications account for most of the morbidity and mortality associated with diabetes. 1–5 Recent data suggest that diabetes at a younger age (45 years) is associated with increased risk of CVD, and the presence of DM takes away the natural protection from coronary heart disease (CHD) in premenopausal women. 2–3 Perhaps the best evidence regarding the impact of DM on CVD is illustrated by data from a recent prospective study that demonstrated that the risk of developing a myocardial infarction in diabetic patients with no prior history of CHD was equivalent to the risk observed in nondiabetic survivors with a prior myocardial infarction who participated in the same study and were followed for a similar duration of 7 years. 5 These data suggest that diabetic patients may already have developed vascular disease by the time a clinical diagnosis of DM is made. Ravikumar et al’s Chennai Urban Population Study (CUPS) provides strong evidence in support of this concept. 6 THE CHENNAI URBAN POPULATION STUDY (CUPS) The results of CUPS 6 evaluated atherosclerotic markers by noninvasive means and showed evidence of vascular disease by revealing endothelial dysfunction and increased carotid intima-media thickness in diabetic patients with no history of coronary artery disease. 6 The investigators utilized standard methods for the evaluation of endothelial function and carotid intima-media thickness. They carefully selected their patients with diabetes, who were not only free of CHD but who also did not have a history of hypertension or smoking. The clinical characteristics of the nondiabetic control subjects enrolled in the study were well matched with those of the diabetic patients. 6

Subgroup interactions in the Heart and Estrogen/Progestin Replacement Study: lessons learned.

The Heart and Estrogen/Progestin Replacement Study (HERS) showed no overall benefit of postmenopausal hormone treatment in women with coronary heart disease (CHD). We analyzed the HERS data to determine whether there were specific subgroups of women who responded differently to treatment, either during the first year or in the overall study. In the search for significant treatment interactions, we analyzed a total of 86 subgroups defined by baseline characteristics. These included demographics and lifestyle factors, laboratory and physical examination variables, medical history and symptoms by self-report, medication use, and prior CHD history by chart review. We examined within-subgroup treatment effects for baseline variables that significantly interacted with treatment assignment. Under the null hypothesis, 4 (5%) of the 86 interactions would be expected to be nominally significant (P<0.05) by chance alone at each time point. Six of the interaction values were P<0.05 at 1 year, and 3 were P<0.05 at trial completion. The findings are discussed in the context of known mechanisms of action and prior scientific knowledge. Use of digitalis and history of myocardial infarction emerged as 2 possible modifiers of the effect of hormone therapy during the first year, and lipoprotein(a) emerged as a possible modifier during the overall study. Extensive post hoc analyses did not identify any subgroup of HERS participants in which postmenopausal hormone treatment was clearly beneficial or harmful, but several possibilities emerged for testing in future trials.

The impact of diabetes mellitus on mortality from all causes and coronary heart disease in women: 20 years of follow-up.

Few data are available on the long-term impact of type 2 diabetes mellitus on total mortality and fatal coronary heart disease (CHD) in women. We examined prospectively the impact of type 2 diabetes and history of prior CHD on mortality from all causes and CHD among 121 046 women aged 30 to 55 years with type 2 diabetes in the Nurses' Health Study who were followed up for 20 years from 1976 to 1996. During 20 years of follow-up, we documented 8464 deaths from all causes, including 1239 fatal CHD events. Compared with women with no diabetes or CHD at baseline, age-adjusted relative risks (RRs) of overall mortality were 3.39 (95% confidence interval [CI], 3.08-3.73) for women with a history of diabetes and no CHD at baseline, 3.00 (95% CI, 2.50-3.60) for women with a history of CHD and no diabetes at baseline, and 6.84 (95% CI, 4.71-9.95) for women with both conditions at baseline. The corresponding age-adjusted RRs of fatal CHD across these 4 groups were 1.0, 8.70, 10.6, and 25.8, respectively. Multivariate adjustment for body mass index and other coronary risk factors only modestly attenuated the RRs. Compared with nondiabetic persons, the multivariate RRs of fatal CHD across categories of diabetes duration (< or =5, 6-10, 11-15, 16-25, >25 years) were 2.75, 3.63, 5.51, 6.38, and 11.9 (P< .001 for trend), respectively. The combination of prior CHD and a long duration of clinical diabetes (ie, >15 years) was associated with a 30-fold (95% CI, 20.7-43.5) increased risk of fatal CHD. Our data indicate that among women, history of diabetes is associated with dramatically increased risks of death from all causes and fatal CHD. The combination of diabetes and prior CHD identifies particularly high-risk women.

Sudden coronary death in women

Objectives The objective of this study was to examine prospectively the incidence, predisposing cardiovascular conditions, and risk factors for sudden death in women compared with men.Methods and Results The study design was a prospective general population examination of a cohort of 2873 women for development of sudden coronary death in relation to antecedent overt coronary heart disease (CHD), cardiac failure, and risk factors for coronary heart disease. Participants were women aged 30 to 62 years participating in the Framingham Study, receiving routine biennial examinations for risk factors and cardiovascular conditions. Among women monitored over a period of 38 years, there were 750 initial coronary events, of which 94 (12%) were sudden cardiac deaths. Of the 292 CHD fatalities in women, 32% were sudden cardiac deaths and 37% of the women had a history of prior CHD. Sudden death incidence in women lagged behind that in men by >10 years. However, above age 75 years, 17% of all CHD events in women were sudden deaths. Sudden death risk in women with CHD was half as high as in men if they had CHD. In both sexes, a myocardial infarction conferred twice the risk of angina. Cardiac failure escalated sudden death risk of women 5-fold but was only one fourth that of men with failure or CHD. Ventricular ectopy increased sudden death risk only in women without prior overt CHD. Except for diabetes, CHD risk factors imposed a lower sudden death risk in women than men. However, even in women, sudden death risk increased over a 17-fold range in relation to their burden of CHD risk factors.Conclusions Sudden death is a prominent feature of CHD in women as well as men, particularly in advanced age. A higher fraction of sudden deaths in women than men is unexpected occurring in the absence of prior overt CHD. It is subject to the same risk factors and as predictable in women as in men. However, at any level of multivariate risk, women are less vulnerable to sudden death than men. (Am Heart J 1998;136:205-12.)

Coronary Heart Disease Risk Factors and LDL Cholesterol-Lowering Efficacy of Fibrates and Simvastatin

The objective of this study was to assess the low-density lipoprotein cholesterol (LDL-C) lowering efficacy of fibric acid derivatives (fibrates) and simvastatin as a function of coronary heart disease (CHD) risk status, stratified according to National Cholesterol Education Program guidelines. Two independent databases were analysed retrospectively. The first data set originated from a consecutive sample of 6340 patients with primary hypercholesterolaemia who completed the diet plus fibrate treatment phase of the Belgian General Practitioners Trial, an open-label, prospective study conducted in a primary care setting. The second data set was derived from 782 participants in five randomised, double-blind studies that each compared a specific fibrate with simvastatin. The main outcome measures were percentage of subjects reaching LDL-C treatment goal, and mean percentage reduction in LDL-C across 5 (first data set) or 3 (second data set) CHD risk strata. In the Belgian General Practitioners Trial, LDL-C lowering efficacy of fibrates was inversely related to CHD risk status as 15.0% of patients with prior CHD reached the LDL-C goal < 4.13 mmol/L(< 160 mg/dl) vs 30.2% of those without CHD and no other risk factor (p < 0.0001 after adjustment for baseline LDL-C and triglycerides). Adjusted mean percentage reductions in LDL-C were 15.1 and 18.2 in these strata, respectively (p < 0.05). Younger age, male gender, high blood pressure, low high-density lipoprotein cholesterol, and history of prior CHD were significant (p < 0.05) negative determinants of both outcome measures in multivariate analyses that adjusted for other risk factors. In the pooled analysis of five randomised trials, the percentage of fibrate-treated patients with prior atherosclerotic disease reaching LDL-C goal < 4.20 mmol/L (< 162 mg/dl) was significantly lower when compared with those without CHD and no risk factor other than LDL-C (adjusted odds ratio = 0.46; p = 0.009), while simvastatin efficacy was similar across CHD risk strata. In conclusion, our results, derived from two independent databases, suggest that the LDL-C lowering efficacy of fibrates, but not of simvastatin, is inversely related to CHD risk status. This exploratory analysis must be confirmed by future prospective studies.

Prevalence of hypercholesterolaemia and coronary heart disease risk factors among Southeast Asian refugees in a primary care clinic

The National Cholesterol Education Program's guidelines for the detection, evaluation, and treatment of high serum cholesterol in adults were employed in screening 155 Southeast Asian refugees in a primary care clinic in Seattle, Washington. In order to determine the need for a therapeutic intervention, information also was collected on the presence of other coronary heart disease (CHD) risk factors. Male gender (39%), cigarette smoking (27%) and hypertension (26%) were the most common CHD risk factors; diabetes mellitus, obesity, a family or prior history of CHD or cerebral/peripheral vascular disease were each noted in less than 10%. The mean serum total cholesterol was 194 mg/dl. Thirty-seven (24%) patients required further lipoprotein analysis based on cholesterol level, history of CHD and risk factors for CHD. Twenty-one (66%) of 32 patients who underwent lipoprotein analysis (14% of all patients) were candidates for a therapeutic intervention for hypercholesterolaemia. Additionally, 14 (44%) patients undergoing lipoprotein analysis had depressed high-density lipoprotein levels (< 35 mg/dl). We conclude that CHD risk factors including hypercholesterolaemia are common in Southeast Asian refugee clinic patients and that in many, a therapeutic intervention may well be justified. Southeast Asian refugees should be routinely screened for hypercholesterolaemia and other CHD risk factors in accordance with the National Cholesterol Education Program's guidelines.

Changing Presentation of Coronary Heart Disease in an Inpatient Population Within the U.S. Military Health Care System

This study examines the changing presentation of coronary heart disease (CHD) in an inpatient population at Brooke Army Medical Center. The specific objectives of the study were to examine the presentation of CHD in a population unbiased by diagnosis-related group (DRG) reimbursements and to assess the importance of unstable angina and prior history of disease in the presentation of CHD. One thousand fifteen discharges in 1985 and 1,304 discharges in 1990 with the diagnosis of CHD were reviewed by cardiologists for evidence of symptomatic heart disease at the time of hospitalization. Forty percent of these charts were accepted into this study. The presentation rates of CHD were 1% with sudden death, 26% with myocardial infarction, 64% with angina, and 9% with congestive heart failure (CHF). During the study period, stable angina, Q-wave infarctions, and the myocardial infarction case fatality rate decreased (p < 0.05) and CHF and non-Q wave infarcts increased (p < 0.001). However, unstable angina was the most common presentation of CHD, and differences (p < 0.05) were noted in the presentation of CHD in patients with and without a prior history of disease. This study demonstrates the significance of unstable angina and prior history of CHD in an environment free of bias from DRG reimbursements.

Smoking cessation following admission to a coronary care unit

To determine the impact of an episode of serious cardiovascular disease on smoking behavior and to identify factors associated with smoking cessation in this setting. Prospective observational study in which smokers admitted to a coronary care unit (CCU) were followed for one year after hospital discharge to determine subsequent smoking behavior. Coronary care unit of a teaching hospital. Preadmission smoking status was assessed in all 828 patients admitted to the CCU during one year. The 310 smokers surviving to hospital discharge were followed and their smoking behaviors assessed by self-report at six and 12 months. None. Six months after discharge, 32% of survivors were not smoking; the rate of sustained cessation at one year was 25%. Smokers with a new diagnosis of coronary heart disease (CHD) made during hospitalization had the highest cessation rate (53% vs. 31%, p = 0.01). On multivariate analysis, smoking cessation was more likely if patients were discharged with a diagnosis of CHD, had no prior history of CHD, were lighter smokers (less than 1 pack/day), and had congestive heart failure during hospitalization. Among smokers admitted because of suspected myocardial infarction (MI), cessation was more likely if the diagnosis was CHD than if it was noncoronary (37% vs. 19%, p less than 0.05), but a diagnosis of MI led to no more smoking cessation than did coronary insufficiency. Hospitalization in a CCU is a stimulus to long-term smoking cessation, especially for lighter smokers and those with a new diagnosis of CHD. Admission to a CCU may represent a time when smoking habits are particularly susceptible to intervention. Smoking cessation in this setting should improve patient outcomes because cessation reduces cardiovascular mortality, even when quitting occurs after the onset of CHD.