Risk Factor For Coronary Heart Disease Events Research Articles

Screening results for subclinical coronary artery calcification in asymptomatic individuals in relation to a detailed parental history of premature coronary heart disease

A parental history of premature coronary heart disease (CHD) is an established risk factor for CHD events in descendants. The study aim was to investigate whether subclinical coronary artery calcification (CAC) differs between asymptomatic individuals (a) without a parental CHD history, (b) with a parental history and (c) without knowledge of parental CHD history. The inclusion of individuals without knowledge of parental CHD history is a new approach. We also differentiated between CHD of mother and father to gain insight into their individual contributions. Data was obtained for 4,301 subjects aged 45-75 years free of overt CHD from the baseline screening of the population-based Heinz Nixdorf Recall study. CAC, measured by electron-beam computed tomography, was modeled conducting logistic regressions. Model 1 included family history, Model 2 was adjusted for age (and gender) and Model 3 added common CHD risk factors. The CAC score was dichotomized using the age and sex-specific 75th percentile. The odds ratio (OR) for CAC ≥ age and sex-specific 75th percentile was 1.33 among individuals with parental premature CHD history (95 % confidence interval [95 %CI]: 1.08, 1.63), which did not change after full adjustment (OR 1.40, 95 %CI: 1.13, 1.74). Individuals with an unknown biological father or mother had a high chance of elevated CAC scores (fully adjusted; father: OR 1.38, 95 %CI: 1.01, 1.90, mother: OR 1.86, 95 %CI: 0.90, 3.84) compared to the reference group. The current study showed an association between parental CHD history and CAC independent of common CHD risk factors. This association affirms the use of parental CHD history in cardiovascular risk assessment among asymptomatic adults in routine practice. The observation that individuals who did not know their mother or father are prone to increased CAC scores needs further confirmation in large scale studies.

Association Between Family History and Coronary Heart Disease Death Across Long-Term Follow-Up in Men

Background— Family history of coronary heart disease (CHD) has been well studied as an independent risk factor for CHD events in the short term (<10 years). However, data are sparse on the association between family history and risk for CHD across long-term follow-up. Methods and Results— We included 49 255 men from the Cooper Center Longitudinal Study. Premature family history of CHD was defined as the presence of angina, myocardial infarction, angioplasty, or bypass surgery in a relative <50 years of age. Cause-specific mortality was obtained from the National Death Index. The association between premature family history and cardiovascular disease (CVD) or CHD death was compared across 3 unique follow-up periods (0–10, >10–20, and >20 years). Lifetime risk was estimated by use of a modified survival analytic technique adjusted for competing risk with non-CVD death as the competing event. After 811 708 person-years of follow-up, there were 919 CHD deaths and 1456 CVD deaths. After adjustment for traditional risk factors, premature family history was associated with CHD mortality >10 to 20 years (1.59; 95% confidence interval, 1.14–2.22) and >20 years (1.43; 95% confidence interval, 1.05–1.95) with wider confidence intervals at 0 to 10 years (1.32; 95% confidence interval, 0.76–2.31). Similar findings were observed for CVD mortality. Compared with men without a family history of coronary artery disease, premature family history was associated with an ≈50% higher lifetime risk for both CHD and CVD mortality (13.7% versus 8.9% and 21% versus 14.1%, respectively). Conclusion— Premature family history was associated with a persistent increase in both CHD and CVD mortality risk across long-term follow-up, resulting in significantly higher lifetime risk estimates.

How Accurate Are 3 Risk Prediction Models in US Women?

Cardiovascular disease (CVD) is the leading cause of death for US women, and nearly two thirds who died suddenly of CVD had no previous symptoms.1 Therefore, it is of great importance to identify “at-risk” women early, so that effective primary prevention strategies can be instituted. A universal recommendation of prevention guidelines is that all asymptomatic women should undergo a global risk assessment.2 Article see p 1748 The Adult Treatment Panel III (ATP-III) of the National Cholesterol Education Program set thresholds for lipid treatment based on one's predicted 10-year risk for a hard coronary heart disease (CHD) event (myocardial infarction or CHD death) using a modified Framingham risk score (FRS).3 There are limitations, however, with use of the ATP-III model for CVD prediction in women. The ATP-III version predicts “hard” CHD events but not angina or revascularizations, even if such revascularizations are performed to manage an acute coronary syndrome. Yet women are more likely to experience “soft” CHD events or strokes than men. Moreover, a single laboratory measurement does not reflect lipid values over a woman's lifetime. The FRS does not take into account family history of premature CHD, a well-established independent risk factor for CHD events.4 Also, because stroke accounts for a higher proportion of CVD events than CHD in women before age 75 years,1 we believe that total CVD risk should be the outcome for prediction and preventive strategies. Indeed, that is the conclusion of the 2011 American Heart Association CVD prevention guidelines for women.5 Furthermore, the FRS only predicts 10-year risk, whereas for women, the issue is most often “lifetime” risk. The Third National Health and Nutrition Examination Survey found that among women without a history of CHD or diabetes, 92% of those aged 60 to 69 years and >98% aged <59 …

Risk of Coronary Heart Disease Events Over 15 Years Among Older Adults With Depressive Symptoms

To determine whether depression status is associated with an increased risk of coronary heart disease (CHD) events, defined as CHD death or nonfatal acute myocardial infarction (MI). Prospective cohort study. An urban primary care practice. Two thousand seven hundred twenty-eight adults (71.4% women, 65.5% black), age 60 years and older, who were screened for depression between 1991 and 1993. Depressive symptom severity at baseline was assessed by the Center for Epidemiologic Studies Depression Scale (CES-D). Data regarding baseline demographic and clinical variables, as well as laboratory evidence of acute MI, were obtained from an electronic medical record system. All-cause mortality and CHD death were determined from the National Death Index through 2006. A total of 423 (15.5%) participants reported elevated symptoms of depression (CES-D score ≥16). During the 13 to 16 years of follow-up, 1,646 (60.3%) individuals died from any cause, and 727 (26.6%) died from CHD or suffered an acute MI. Cox proportional hazards models revealed that individuals with elevated depressive symptoms were more likely to experience a CHD event, even after adjustment for demographics and comorbid health conditions (relative risk = 1.46, 95% confidence interval: 1.20-1.77). Depression status was also a significant predictor of all-cause mortality in adjusted models. We report the longest prospective study to date to examine depression status as an independent risk factor for CHD among a cohort of older adults including large numbers of women and underrepresented minorities. The present findings underscore the need to consider depression as a common and modifiable risk factor for CHD events among older adults.

Diabetes Mellitus, Preexisting Coronary Heart Disease, and the Risk of Subsequent Coronary Heart Disease Events in Patients Infected With Human Immunodeficiency Virus

Although guidelines in individuals not infected with the human immunodeficiency virus (HIV) consider diabetes mellitus (DM) to be a coronary heart disease (CHD) equivalent, there is little information on its association with CHD in those infected with HIV. We investigated the impact of DM and preexisting CHD on the development of a new CHD episode among 33,347 HIV-infected individuals in the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D Study). Over 159,971 person-years, 698 CHD events occurred. After adjustment for gender, age, cohort, HIV transmission, ethnicity, family history of CHD, smoking, and calendar year, the rate of a CHD episode was 7.52 times higher (Poisson regression, 95% CI 6.02 to 9.39, P=0.0001) in those with preexisting CHD than in those without preexisting CHD, but it was only 2.41 times higher (95% CI 1.91 to 3.05, P=0.0001) in those with preexisting DM compared with those without DM. No statistical interactions were apparent between either diagnosis and sex; although older people with DM had an increased CHD rate compared with younger people, older people with preexisting CHD had a lower event rate. A statistically significant interaction between preexisting DM and CHD (P=0.003) suggested that the CHD rate in those with preexisting CHD and DM is lower than expected on the basis of the main effects alone. DM and preexisting CHD are both important risk factors for CHD events in HIV-infected individuals. There is a need for targeted interventions to reduce the risk of CHD in both high-risk groups of HIV-infected individuals.

Impact of Obesity on the Pathogenesis and Prognosis of Coronary Heart Disease

Obesity has a significant adverse effect on coronary heart disease (CHD) risk factors, including hypertension, dyslipidemia, and the metabolic syndrome/diabetes. Obesity is an independent risk factor for CHD events; however, obese patients with CHD generally have a more favorable prognosis, with the worst prognosis associated with either underweight or morbidly obese patients. In this manuscript, the authors review the impact of obesity on overall CHD risk as well as the prognosis of obese patients with established CHD.

A simple and precise method for measuring HDL-cholesterol subfractions by a single precipitation followed by homogenous HDL-cholesterol assay

HDL consists of two major subfractions, HDL2 and HDL3. This paper describes a simple method for assaying HDL subspecies by combining a single precipitation with a direct high density lipoprotein-cholesterol (HDL-C) assay. A precipitation reagent (0.06 ml) containing 1,071 U/ml heparin, 500 mmol/l MnCl2) and 12 mg/ml dextran sulfate was added to a serum (0.3 ml). The sample was incubated and centrifuged at 10,000 rpm for 10 min. HDL3-C was measured by a homogenous HDL-C assay in the supernatant, and HDL2-C was estimated by subtracting the HDL3-C from the direct HDL-C. The HDL3-C and HDL2-C values determined by the precipitation method were identical to those determined by ultracentrifugation, and there were excellent correlations between the methods in the measurements of HDL3-C and HDL2-C (r = 0.933 and 0.978, respectively; n = 102). The two methods also proved to be highly correlated in the measurement of apolipoprotein A-I and A-II in HDL subfractions. The HDL-C subfractions determined by ultracentrifugation were more closely associated with the homogenous HDL-C assay than with the total cholesterol assay, especially in the hypertriglyceridemic samples. Our method is far simpler and more precise than the classical dual precipitation method for HDL-C subfractions, and it can be easily performed in a routine chemical laboratory.

Serum Zinc Level and Coronary Heart Disease Events in Patients With Type 2 Diabetes

Low serum zinc level may predispose nondiabetic subjects to cardiovascular diseases. Our aim was to investigate whether serum zinc level predicts coronary heart disease (CHD) events in subjects with type 2 diabetes The original study population consisted of 1,059 patients with type 2 diabetes, aged 45-64 years. Mean duration of diabetes was 8 years. Serum zinc values were available from 1,050 subjects. CHD mortality and the incidence of nonfatal myocardial infarction (MI) were assessed in a 7-year follow-up. During the follow-up, 156 patients died from CHD and 254 patients had a fatal or nonfatal MI. Patients with serum zinc concentration < or = 14.1 micromol/l at baseline had a higher risk for death from CHD than patients with serum zinc level > 14.1 micromol/l (20.8 and 12.8%, respectively; P = 0.001) The risks for fatal or nonfatal MI were 30.5 and 22.0%, respectively (P = 0.005). In Cox regression analyses, low serum zinc concentration was significantly associated with CHD mortality (relative risk [RR] 1.7, P = 0.002) and all CHD events (RR 1.37, P = 0.030), even after adjustment for confounding variables. In this large cohort of type 2 diabetic patients, low serum zinc level was an independent risk factor for CHD events.

Family History of Premature Coronary Heart Disease and Coronary Artery Calcification

A family history of premature coronary heart disease (CHD) is a known risk factor for CHD events. The purpose of this study was to assess the strength of the association between a family history of premature CHD and coronary artery calcification (CAC) in a multiethnic cohort of asymptomatic individuals. We also sought to determine whether individuals with a reported family history of premature CHD have an increased atherosclerotic burden among those classified as being at low to intermediate risk on the basis of the conventional Framingham risk score. The association of family history of premature CHD with CAC was assessed in 5347 asymptomatic individuals (47% men; mean age 62+/-10 years) in the Multi-Ethnic Study of Atherosclerosis (MESA). The demographics (age, gender, and race)-adjusted OR for CAC > 0 with versus without a family history of premature CHD was 1.94 (95% CI, 1.64 to 2.29). On adjustment for CHD risk factors, the association was slightly attenuated to an OR of 1.84 (95% CI, 1.55 to 2.19). Family history of premature CHD was significantly associated with CAC in all ethnic groups. The age-, gender-, and race-adjusted prevalence of CAC > 0 was significantly higher with presence of any family history of premature CHD than for those with no family history of premature CHD among individuals classified as low risk (35% versus 23%, P<0.0001) and among those at intermediate risk (70% versus 60%, P=0.01). Similarly, the prevalence of age-gender-race-based CAC > or = 75th percentile in low-risk (24% versus 14%, P=0.0003) and intermediate-risk (34% versus 20%, P<0.001) individuals was also higher among those with a family history of premature CHD. Compared with those without a family history of premature CHD, the association with the presence of CAC was strongest in participants reporting such history in both a parent and a sibling (odds ratio, 2.74; 95% CI, 1.64 to 4.59), followed by those reporting a family history in a sibling only (odds ratio, 2.06; 95% CI, 1.64 to 2.58) and those reporting a family history of premature CHD only in a parent (odds ratio, 1.52; 95% CI, 1.19 to 1.93). An association between family history of premature CHD and the presence of any CAC, as well as advanced CAC, was observed in the present population-based multiethnic study. The relationship was independent of other risk factors and Framingham risk score, which supports the utility of including information on family history of premature CHD in current methods of global risk assessment and practice guidelines.

Characteristics of Metabolic and Lifestyle Risk Factors in Young Japanese Patients With Coronary Heart Disease A Comparison With Older Patients

Coronary heart disease (CHD) is recognized as a lifestyle-related disease and is the second leading cause of death in Japan. However, the cardiac risk factor profile of young patients with CHD has not been clarified in suburban areas of Japan. Our study aimed to determine metabolic and lifestyle risk factors in young patients and compare them with older patients living in suburban areas of Nagano Prefecture. A multicenter study was conducted in 86 young (aged less than 40 years) and 91 older (aged 50 years and over) patients diagnosed with CHD from 1992 to 2002. There was a strong association between obesity and the occurrence of CHD events in young patients (odds ratio = 3.61, P = 0.006). Lifestyle in the young patients was characterized by a lack of physical activity and regular physical activity was found to decrease the risk of the CHD events in these patients (odds ratio = 0.31, P = 0.030). In older patients, hypertension was identified as an independent risk factor for CHD events. The results of the present study have demonstrated that obesity and a lack of regular physical exercise are independent risk factors for CHD events in younger patients. Thus, the data may be useful for the effective screening of high-risk individuals and the development of educational programs for the prevention of CHD, especially in younger Japanese.

Elevated plasma homocysteine level is an independent predictor of coronary heart disease events in patients with type 2 diabetes mellitus.

High plasma homocysteine level has been associated with increased risk for coronary heart disease (CHD) events in nondiabetic individuals, especially in those with previously diagnosed CHD. In persons with type 2 diabetes mellitus, the association between homocysteine level and cardiovascular disease may be stronger than that in nondiabetic individuals, but no large prospective studies have examined the relationship between homocysteine level and CHD mortality in persons with type 2 diabetes. To investigate whether moderately elevated plasma homocysteine levels are independently related to increased incidence of fatal and nonfatal CHD events in persons with type 2 diabetes. Prospective study. Finnish sample of patients with type 2 diabetes. 462 men and 368 women who were 45 to 64 years of age at baseline. Coronary heart disease mortality and incidence of nonfatal myocardial infarction during the 7-year follow-up. Participants with plasma homocysteine levels of 15 micromol/L or more at baseline had a higher risk for CHD death than those with plasma homocysteine levels less than 15 micromol/L (26.1% and 13.5%, respectively; P = 0.005). The risks for all CHD events were 36.2% and 22.6%, respectively (P = 0.011). In Cox regression analyses, elevated plasma homocysteine level was significantly associated with CHD mortality (P < 0.001) and all CHD events (P = 0.002) even after adjustment for confounding variables, including creatinine clearance. In participants without myocardial infarction at baseline, moderate hyperhomocysteinemia was also associated with CHD mortality and all CHD events in univariate (P < 0.001 and P = 0.006, respectively) and multivariate Cox regression analyses (P < 0.001 and P = 0.004, respectively). In this large cohort of patients with type 2 diabetes, plasma homocysteine level was a strong and independent risk factor for CHD events.

Hemostatic factors as predictors of coronary events and total mortality: The FINRISK '92 Hemostasis Study.

The role of hemostatic factors as predictors of coronary heart disease (CHD) and total mortality is poorly understood. Therefore, we carried out a prospective cohort study in Finland. In 1992, a random population sample of 2378 men and women aged 45 to 64 years was investigated and then followed up until December 31, 1998. During the follow-up, 133 CHD events were observed; 73 were among participants free of CHD at baseline. The total number of deaths was 124. After adjustment for traditional risk factors and prevalent CHD at baseline and correction for regression dilution bias, a 1-SD increase in plasminogen was associated with a 1.41-fold (95% CI 1.09 to 1.81) increase in CHD risk. The predictive power of plasminogen depended significantly on the level of total cholesterol being stronger for persons with high cholesterol. A 1-SD increase in fibrinogen was associated with a 1.23-fold (95% CI 1.05 to 1.44) increase in all-cause mortality, but its association with CHD events did not reach statistical significance. Factor VII antigen or coagulant activity or lipoprotein(a) were not independent predictors of CHD risk. These findings support the role of plasminogen as a risk factor for CHD events.

Managing dyslipidemia in older adults.

To summarize and critically review clinical trial data regarding dyslipidemia as a risk factor for coronary heart disease (CHD) and the efficacy and safety of lipid-lowering interventions in older adults. Based on these data, clinical recommendations for diagnosing and managing dyslipidemia in older adults are provided. Peer-reviewed journal articles were identified by a MEDLINE search and a review of journal article references. Studies that were performed exclusively in subjects older than 65 years or that included a large subgroup of older adults were included. Elevated low density lipoprotein and total cholesterol levels are independent risk factors for CHD events in patients aged older than 65 years. Older adults have a higher risk of mortality attributable to hypercholesterolemia. Diet and lipid-lowering medications safely and effectively lower cholesterol levels in this age group. Exercise increases high-density lipoprotein cholesterol levels and decreases triglyceride levels. If accompanied by weight loss, exercise may reduce low-density lipoprotein and total cholesterol levels. Improving lipid levels in older adults with CHD decreases the risk of future coronary events by up to 45%, and significant effects on outcome measures may be observed within 2 years of the initiation of therapy.

Primary prevention of cardiovascular disease in high-risk patients: physiologic and demographic risk factor differences between african american and white american populations

Ischemic heart disease is the leading cause of death in the United States among Americans of African as well as of European ancestry. African Americans have the highest overall coronary heart disease (CHD) mortality rate and the highest out-of-hospital coronary death rates of any ethnic group in the United States, particularly at younger ages. The reasons for this excess CHD mortality among African Americans have not been fully elucidated but may be attributed to a high prevalence of coronary risk factors, patient delays in seeking medical care, limited access to and utilization of cardiac services, and undertreatment of high-risk individuals. The high prevalence of modifiable risk factors in African Americans provides a major opportunity for CHD prevention and risk reduction in this high-risk population. Hypertension, left ventricular hypertrophy (LVH), diabetes mellitus, cigarette smoking, obesity, physical inactivity, and multiple CHD risk factors all occur more frequently in African Americans than in whites. –7 The predictive value of most conventional risk factors for CHD appears to be similar for African Americans and whites. However, the risk of death and other sequelae attributable to some risk factors, such as hypertension and diabetes, is disproportionately greater for African Americans, –11 and current risk assessment algorithms may not have the same predictive value in African Americans as in whites. Hypertension and LVH are more prevalent, develop at younger ages, and are associated with three to five times higher mortality rates in African Americans than in whites. Moreover, African Americans experience greater cardiovascular and renal damage at any level of hypertension than do whites. Elevations in both diastolic and systolic blood pressures increase cardiovascular risk. However, elevated systolic blood pressure is a more powerful predictor of CHD, heart failure, stroke, end-stage renal disease, and overall mortality than is elevated diastolic blood pressure. LVH, when present, is more predictive of CHD morbidity and mortality than is hypertension, cigarette smoking, or hypercholesterolemia. Hypertension and LVH increase the predisposition to arrhythmia and potentially lethal silent ischemic events. –10,12 Both hypertension and LVH impart a particular risk for a poor outcome in African Americans. In a study of African Americans with LVH and coronary disease, LVH accounted for 40% of the attributable risk of death. In the Meharry–Hopkins physician cohort study, hypertension was the best predictor of cardiac events in African American physicians, whereas smoking, cholesterol, and a family history of CHD were better predictors of cardiac events in white physicians. Thus, both hypertension and LVH are common and important risk factors for CHD events in African Americans. Risk prediction algorithms that do not include hypertension and LVH may have less predictive value in African Americans than in other populations. The prevalence of diabetes in African Americans has tripled during the past 30 years, is two to three times greater than in whites, and is associated with a greater burden of macrovascular and microvascular disease complications. Individuals with diabetes are two to three times more likely to experience a CHD event than are nondiabetics, with approximately 60% of deaths in diabetics due to CHD. It is not known why diabetes is substantially more prevalent in African Americans and other high-risk minorities than in whites or why the disease appears to run a more aggressive clinical course in these populations. The cornerstones of effective cardiovascular disease prevention and risk reduction in patients with diabetes are glycemic control, vigorous modification of other CHD risk factors, and ongoing patient monitoring to facilitate early disease detection and prompt intervention. Most population-based surveys indicate that African Americans have lower total serum cholesterol levels and a similar or lower prevalence of hypercholesterolemia compared with whites. – 6,18 The relation between total cholesterol levels and CHD mortality was the same among 23,490 black men screened for the Multiple Risk Factor Intervention Trial (MRFIT) as among 325,384 white men during an average follow-up period of approximately 12 years. However, the first National Health and Nutrition Examination Survey epidemiologic folFrom the Division of Cardiovascular Medicine, State University of New York Health Science Center at Brooklyn, Brooklyn, New York. Requests for reprints should be addressed to Luther T. Clark, MD, Division of Cardiovascular Medicine, State University of New York Health Science Center at Brooklyn, 450 Clarkson Avenue, Brooklyn, New York 11203.

The Rochester Coronary Heart Disease Project: Effect of Cigarette Smoking, Hypertension, Diabetes, and Steroidal Estrogen Use on Coronary Heart Disease Among 40- to 59-Year-Old Women, 1960 Through 1982

A population-based case-control study of coronary heart disease (CHD) risk in young women attributable to cigarette smoking, hypertension, diabetes, and steroidal estrogen use was conducted among residents of Rochester, Minnesota. All newly diagnosed cases of CHD (sudden unexpected death [SUD], N = 18; myocardial infarction [MI], N = 90; and angina, N = 133) among female Rochester residents 40 to 59 years of age during the years 1960 through 1982 were identified, and two community control subjects were matched for age and duration of community medical record. The overall adjusted odds ratio (OR) for the association between steroidal estrogen use and definite CHD (MI and SUD) was 0.6 (95% confidence interval [CI] = 0.2 to 1.3). Smoking (OR = 5.1; 95% CI = 2.3 to 11.6), hypertension (OR = 4.8; 95% CI = 2.3 to 10.2), and diabetes (OR = 8.4; 95% CI = 1.6 to 44.5) were strong risk factors for CHD events. If considered causal, cigarette smoking accounted for 64% of all MIs and SUDs in the community, hypertension accounted for 45%, and diabetes accounted for 13%. Although steroidal estrogen exposure reduced CHD among these women by 14%, giving steroidal estrogens to all women in this age group might reduce the population rates of MI by as much as 45%.