Cross-spouse correlates of blood pressure in hypertension-prone families in Utah

This study used a subsample of 543 married couples from a large group of families in Utah, who were originally studied to assess the genetic and environmental determinants of hypertension. Excluding individuals on medication and controlling for the major risk factors for hypertension, evidence was obtained for cross-spouse blood pressure associations equal in magnitude to self-psychosocial and demographic measures. Observed spouse-spouse similarity for blood pressures remained significant after adjustment for shared psychological factors. It is speculated that different aspects of each spouse's nonmarital environments (e.g. work, social support) have differential impacts on the marital environment and on physiologic indicators of health.

Validity of cigarette smoking habits in three epidemiologic studies in Utah

Utah has lower incidence and mortality for many smoking-related forms of cancer and heart disease. It is an important epidemiologic question to assess whether the population attributable risk associated with cigarette smoking in this low-risk population is biased from under-reporting because of societal pressures not to smoke. To answer this question, we compared reported cigarette use to serum cotinine values in three different epidemiologic study designs. Included in these analyses were data from men interviewed for a cross-sectional study of dietary intake and hormones, women interviewed as a part of a case-control study of cervical cancer, and men interviewed in conjunction with a cardiovascular disease and hypertension family follow-up study. Cross-sectional study participants reported accurate cigarette usage 93.8% of the time; case-control participants accurately reported cigarette use 98.5% of the time; participants interviewed in the family cohort study correctly reported usage 82.8% of the time. Most inaccurate reporting of smoking was by exsmokers being followed for a disease known to be linked to smoking. The low attributable risk of smoking related to diseases in Utah is not from underreporting of cigarette smoking, and makes Utah an ideal population to examine other risk factors for diseases where smoking increases risk.

Genotyping and sequence analysis of apolipoprotein E isoforms

Apolipoprotein E (apoE), a polymorphic plasma protein, is essential for catabolism of lipoproteins by receptor-mediated endocytosis. One of the apoE isoforms (E2) differs in its binding affinity to specific receptors and contributes to variations in lipoprotein metabolism. Diagnosis of apoE isoforms is done by isoelectric focusing, but it is hindered by various degrees of post-translational sialylation of the apoE protein. Electrophoretically silent structural variations may also escape detection by this technique. We describe a method for genotyping apoE based on hybridization of allele-specific oligonucleotides with enzymatically amplified genomic DNA, which permits unambiguous diagnosis of six common apoE phenotypes within 24 h. Among 100 E2 alleles present in 81 unrelated individuals genotyped by this technique, we found two rare structural mutants of apoE in addition to the common E2 form, E2(158Arg----Cys). Automated sequencing of amplified DNA identified the rare mutants as E2(136Arg----Ser) and E2(145Arg----Cys). The genotypic method may complement or even replace isoelectric focusing for routine determination of apoE phenotypes and for identification of rare structural variants.

Relation between family history of coronary artery disease and coronary risk variables

The relation between family history of coronary artery disease (CAD) and coronary risk variables was examined in 1,058 Utah adults. Subjects were divided into 3 family history score groups (low, intermediate and high) and the effects of 60 potential risk variables were assessed using multiple stepwise discriminant analysis. After controlling for age effects, the variables entering the discriminant function equation (p less than 0.01) were cholesterol, years smoking cigarettes, high-density lipoprotein cholesterol and triceps skinfold thickness. Although normal blood pressure variation did not discriminate among family history groups, those with a positive family history of CAD were more likely to develop hypertension than those without a family history (age-adjusted relative risk 1.79, with 95% confidence limits 1.03 and 3.09). In spite of significant differences among family history score groups with regard to risk variables, the discriminant analysis classified only 39% of subjects into the correct group. It was concluded that other unknown risk variables must mediate the effects of family history of CAD. Thus, family history should be considered an independent risk factor for CAD.

Family history as an independent risk factor for incident coronary artery disease in a high-risk cohort in Utah

To test independence of family history of coronary artery disease (CAD) as a risk factor for the development of new clinical CAD, data collected at 2 clinic visits on 1,196 men and women, ages greater than 20 years, were analyzed using Cox proportional hazard method. During a mean follow-up of 2.5 years, 16 new CAD cases were observed. After adjustment for age, sex, total cholesterol, high density lipoprotein cholesterol, hypertension, diabetes, cigarette smoking and body mass index, family history remained a highly significant predictor of future CAD (p = 0.0017). Only age was a more significant covariate (p = 0.0001) than family history. Sex (p = 0.00074) and serum total cholesterol (p = 0.015) also contributed significantly to CAD incidence while high density lipoprotein cholesterol, hypertension, diabetes, body mass index and several interaction terms did not improve the prediction in this population. These results provide evidence for the existence of other heritable risk factors which appear to contribute strongly to the occurrence of early CAD in many high-risk families.

Genetic linkage between lipoprotein(a) phenotype and a DNA polymorphism in the plasminogen gene

Coronary heart disease risk correlates directly with plasma concentrations of lipoprotein(a) (Lp(a)), a low-density lipoprotein-like particle distinguished by the presence of the glycoprotein apolipoprotein(a) (apo(a)), which is bound to apolipoprotein B-100 (apoB-100) by disulfide bridges. Size isoforms of apo(a) are inherited as Mendelian codominant traits and are associated with variations in the plasma concentration of lipoprotein(a). Plasminogen and apo(a) show striking protein sequence homology, and their genes both map to chromosome 6q26-27. In a large family with early coronary heart disease and high plasma concentrations of Lp(a), we found tight linkage between apo(a) size isoforms and a DNA polymorphism in the plasminogen gene; plasma concentrations of Lp(a) also appeared to be related to genetic variation at the apo(a) locus. We found free recombination between the same phenotype and alleles of the apoB DNA polymorphism. This suggests that apo(a) size isoforms and plasma lipoprotein(a) concentrations are each determined by genetic variation at the apo(a) locus.

Health family trees: a tool for finding and helping young family members of coronary and cancer prone pedigrees in Texas and Utah

We report on the feasibility and utility of a new approach for identifying the small percentage of families in the general population with strong familial predisposition to early coronary heart disease, strokes, and common familial cancers (breast, colon, lung), using the "Health Family Tree," a medical family history. A total of 24,332 "trees" were completed by parents and students in 37 high schools in 14 urban and rural communities in Texas and Utah during the years 1980-86. Completed "trees" were obtained from 68 per cent of all enrolled students. High-risk families, included 1,796 families with early coronary disease (7.5 per cent of all student families or 3.7 per cent of their parents' families), 870 stroke families (3.6 per cent), and 415 cancer prone families (1.7 per cent). Among these 3,081 high-risk families there were 8,245 family members already reported to have been diagnosed by a physician to have the familial disease of interest and 43,269 high risk unaffected siblings and offspring of these persons. The average cost per identified high-risk unaffected person was under $10. We conclude that the "Health Family Tree" is a feasible and cost-effective way to find high-risk families.

Inference of a molecular defect of apolipoprotein B in hypobetalipoproteinemia by linkage analysis in a large kindred

Heterozygous hypobetalipoproteinemia is characterized by reduced plasma concentrations of LDL cholesterol, total triglycerides, and apo B to less than 50% of normal values. The molecular basis of this disorder remains unknown. The phenotype cosegregates with a DNA haplotype of the apo B gene in an Idaho pedigree, with a maximum decimal logarithm of the ratio (LOD) score of 7.56 at a recombination rate of zero. Individuals carrying this haplotype had total cholesterol levels of 96 mg/dl, LDL cholesterol levels of 37 mg/dl, triglycerides levels of 51 mg/dl, and apo B levels of 38 mg/dl. This study strongly suggests that apo B mutations underlie hypobetalipoproteinemia, and demonstrates the power of the candidate gene approach in linkage analysis for unraveling genetic determinants in metabolic disorders of undefined etiology.

Hypertension and sodium-lithium countertransport in Utah pedigrees: evidence for major-locus inheritance

Likelihood analysis was used to test for evidence that an allele at a major locus elevates rates of sodium-lithium countertransport (SLC) in a sample of 1,989 members of 89 Utah pedigrees. The pedigrees were ascertained through two or three sibs who died of stroke before age 74 years (stroke pedigrees), through hypertensive and normotensive probands of the Salt Lake Center of the Hypertension Detection and Followup Program (HDFP pedigrees), or through men who suffered a myocardial infarction before age 55 years (coronary pedigrees). Major-locus inheritance could be rejected in the total sample; transmission probability estimates of tau1 = .972, tau2 = .520, tau3 = .185 differed significantly from Mendelian transmission specified by tau1 = 1, tau2 = 1/2, tau3 = 0. However, heterogeneity between ascertainment groups was significant (chi2(18) = 40.06, P less than .01) and justified analysis within subsets of the sample. In the stroke pedigrees, evidence of major-locus inheritance was not found; polygenic heritability was estimated as .647. In the HDFP pedigrees, estimates of tau1 = .987, tau2 = .430, tau3 = .506 differed significantly from Mendelian transmission; the inferred model consisted of a mixture of two distributions incompatible with both Mendelian and environmental transmission but compatible with polygenic inheritance within distributions. In the coronary pedigrees, the hypothesis of Mendelian transmission could not be rejected. In the coronary pedigrees, the evidence supported an incompletely recessive allele with a frequency of .227 which elevated the level of SLC to a mean of .530 mmol/liter RBC/h.(ABSTRACT TRUNCATED AT 250 WORDS)

Familial dyslipidemic hypertension. Evidence from 58 Utah families for a syndrome present in approximately 12% of patients with essential hypertension

Population-based sibships with essential hypertension diagnosed before the age of 60 years are being screened in Utah to find two or more hypertensive siblings with the same biochemical abnormality as a clue to an inherited cause for their specific type of hypertension. Among 131 hypertensive subjects in 58 sibships, concordant abnormalities in fasting serum lipid concentrations were observed in two or more siblings in 48% of the sibships. After adjusting for effects of antihypertensive medications, abnormal values reported in only 10% of the Lipid Research Clinics data were observed in 30% of patients for serum triglycerides, 19% for serum low-density lipoprotein cholesterol, and 39% for high-density lipoprotein cholesterol. More than one lipid level was abnormal in almost all concordant sibships, suggesting an association between hypertension and a syndrome of mixed lipid abnormalities, probably familial combined hyperlipidemia (renamed "familial combined dyslipidemia" because of common low high-density lipoprotein cholesterol levels). We conclude that familial dyslipidemic hypertension may be a specific syndrome with lipid abnormalities more severe than blood pressure elevations.

A digoxin-like factor associates with erythrocyte sodium concentration, sodium transport, and ouabain binding

To investigate what effects a circulating digoxin-like factor (DLF) might have on sodium metabolism, we examined data collected on 1,327 individuals screened in the Cardiovascular Genetics Clinic at the University of Utah. This sample included 639 unmedicated adults, 582 youths under age 18, and 106 medicated hypertensive individuals, all on an unrestricted diet when attending clinic. No individuals look digitalis. A digoxin assay detected measurable levels of plasma DLF in 13.4% of the youths, 17.2% of the normotensive adults, and 25.5% of the hypertensive adults. In all three groups of individuals, those with a measurable DLF had a significantly lower erythrocyte ouabain sensitive sodium efflux rate constant (adjusted for age, sex and body mass) than those with no measurable DLF (p less than 0.01). Normotensive and hypertensive adults with measurable DLF also had an increased erythrocyte intracellular sodium level. Either the number of ouabain binding sites and/or the apparent affinity for ouabain were reduced for those with DLF levels in all three groups. There was a small nonsignificant increase in blood pressure for the normotensive adults and youths with a measurable DLF. We conclude that plasma DLF is associated with reduced ouabain sensitive sodium transport and increased intracellular sodium concentration, possibly due to changes in the number of or the competition for the Na+ - K+ ATPase sites.

Lifestyle and blood pressure levels in male twins in Utah

Healthy male monozygotic (MZ) and dizygotic (DZ) twin pairs (MZ pairs = 77; DZ pairs = 88) were studied to assess the effect of dietary intake, physical activity, physical fitness, body mass index (BMI), sum of the triceps and subscapular skinfold measurements, alcohol and caffeine consumption, and smoking patterns on blood pressure. Data on physical activity, detailed dietary intake, medical history, and demographics were obtained from a questionnaire. A bicycle ergometer was used to estimate level of fitness; other medical information was ascertained from physical examination. After normalizing the study variables, intraclass correlations for BMI and the sum of the triceps and subscapular skinfold measurements were higher in MZ than in DZ twin pairs (BMI: MZ r = 0.76, DZ r = 0.48; skinfolds: MZ r = 0.73, DZ r = 0.28), as were VO2max(MZ r = 0.63, DZ r = 0.25) and post-bike heart rate (MZ r = 0.69, DZ r = 0.19). Both systolic (SBP) and diastolic blood pressure (DBP) had high heritability estimates (SBP = 0.60, and DBP = 0.66). Using factor analysis, four major lifestyle factors were identified and categorized as: 1) dietary intake; 2) a factor heavily weighted by cigarette smoking, alcohol and caffeine consumption; 3) fatness; 4) physical activity and physical fitness. Adjustment for these factors did not alter heritability estimates for either SBP or DBP.

The inheritance of intraerythrocytic sodium level

Intraerythrocytic sodium level (RBC Na) was measured on 1,800 normotensive members of 64 Utah pedigrees ascertained through hypertensive or normotensive probands, sibs with early stroke death, or brothers with early coronary disease. Likelihood analysis provided evidence that RBC Na was determined by four alleles at a single locus. Each allele was recessive to all alleles associated with a lower mean level. The four resultant distributions occurred in the frequencies: 0.8%, 89.3%, 9.7%, and 0.2% with corresponding means (mmol/1 RBC) of 4.32, 6.67, 9.06, and 12.19, respectively. The major locus explained 29.0% of the variance in RBC Na; polygenic inheritance explained another 54.6%. A higher frequency of the genotypes for high RBC Na in pedigrees when the proband was hypertensive than normotensive provided evidence that this major locus increases susceptibility to hypertension.

Recruitment of members of high-risk Utah pedigrees

Cardiovascular Genetics Research Projects in Utah are designed to investigate genetic and environmental determinants of early coronary disease, stroke, and hypertension in population-based pedigrees. Early coronary disease is defined as the occurrence of documented coronary death or myocardial infarction before age 55. Detailed recruitment experience is reported for 2500 persons age 3-83 years in 98 high-risk pedigrees from three ascertainment groups: 1. Descendants of sibships with two or more stroke deaths before age 75. 2. Descendants of sibships with two or more coronary deaths before age 55. 3. First- and second-degree relatives of hypertensive and normotensive probands randomly selected from the Utah Hypertension Detection and Follow-up Program. A response rate of 94% of invited adults attending the first 4-hour clinic visit for detailed screening in 1980-1983 was achieved by multiple telephone, mail, and personal contacts and rescheduling of missed clinic appointments. For the same participants, a second screening cycle in 1983-1986 showed a 91% response of invited adults. Second visit response rates were examined within subgroups according to data collected at the first clinic visit. Below average response rates included 79% of persons with fewer than 12 years of education, 84% of current smokers, and 86% of divorced persons. Above average response rates included 93% of persons attending college and 95% of persons with total family income above $25,000. There were no differences in response according to sex or age. The average cost of recruitment was $59 per person and represented about 10% of the total budget for the High-Risk Pedigree Project.

Genetic studies of cation tests and hypertension

Several tests of cation concentration and transport are being studied among members of large Utah pedigrees as part of a study of the genetic and environmental determinants of essential hypertension. Corrected urinary sodium excretion and plasma sodium concentration correlated well in spouses and siblings (r = 0.21-0.54, p less than 0.001), suggesting the effects of shared family environment (e.g., sodium intake). Intraerythrocytic sodium concentration and sodium-lithium countertransport showed no significant correlation in spouses and very significant correlations between siblings and between parents and offspring (r = 0.34-0.58, p less than 0.001), suggesting mostly genetic determination. Using maximum likelihood tests of different genetic models, both sodium-lithium countertransport and intraerythrocytic sodium showed predominantly polygenic determination (H2 = 70%) and some possible major gene determinants (H2 = 18-25%) for a total heritability of 89 to 95% for these characteristics. These data suggest both genes and shared family environment contribute to the familiality of cation tests. They also illustrate the need and utility of quantitative methods for objective analysis of pedigree data.

Familial correlations from genes and shared environment for urine, plasma, and intraerythrocytic sodium

Spouse-spouse, sib-sib, and parent-offspring correlations were calculated for urinary, plasma, and intracellular sodium levels on over 1,900 persons aged 3-86 years in 98 Utah kindreds. For 36 hours prior to their clinic visit, 31% of the sample was salt-loaded with salt tablets, while the rest followed their normal diet. For those on their normal diet, urine creatine-, age-, and sex-adjusted urinary sodium excretion from a timed 12-hour overnight sample showed similar and significant correlations between spouses (r = .29), sibs less than 20 years old (r = .38), and parent-offspring pairs for offspring less than 20 years old (r = .29). This contrasted with the lower correlations between sibs 20 years of age and older (r = .10) and parent-offspring pairs for offspring 20 years of age and older (r = .13), presumed to live in different households. Adult plasma sodium sib-sib (r = .13) and parent-offspring (r = .15) correlations were similar to the urinary sodium correlations, while the spouse-spouse (r = .48), the sib-sib (r = .64), and the parent-offspring (r = .63) correlations for those presumed to live in the same household nearly doubled. Intracellular sodium correlations for the adult sibs (r = .32) and offspring (r = .36) were over twice as large as for urinary or plasma sodium, although the spouse-spouse correlation (r = .37) remained large also.(ABSTRACT TRUNCATED AT 250 WORDS)

Preliminary evidence for genetic determination of intraerythrocytic sodium concentration in Utah pedigrees

Intraerythrocytic sodium concentration has been reported to be increased in hypertensive individuals and some of their normotensive relatives. We investigated the "familiality" of this trait in 572 nonhypertensive subjects from 34 Utah kindreds. Most of these kindreds were selected because of a high incidence of hypertension, heart attack, or stroke. Intraerythrocytic sodium concentration was correlated with the sex of the subject and suprailiac skinfold thickness. Intraerythrocytic sodium concentration was adjusted by linear regression for these 2 factors. The residual values were positively correlated in parent-offspring pairs and among sibs, both those presumed to be living together and those presumed to be living apart. The spouse-spouse correlation was not significant. Pedigree analysis suggested a mixed major-gene/polygenic model of inheritance, but these data did not allow us to distinguish between dominant and recessive inheritance for the major gene component. Total heritability due to both major-gene and polygenic components was estimated to be 90-95%; the proportion of the total variance due to polygenes was estimated to be 60-75%. These results suggest that further study of the relationship between the inheritance of intraerythrocytic sodium and the pathophysiology of hypertension is warranted.

Blood pressure reactivity in adult male twins

The purpose of the present investigation was to examine possible genetic contributions to cardiovascular reactivity by contrasting patterns of association in 82 monozygotic (MZ) and 88 dizygotic (DZ) adult male twin pairs (age range = 21 to 61 years, M = 35 years). Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were recorded during baseline and during a mental arithmetic task (i.e., serial subtraction). The task produced significant elevations in all three cardiovascular measures (i.e., 10 mmHg SBP, 8 mmHg DBP, and 6 bpm HR, respectively). Levels of SBP and DBP reactivity were significantly correlated in MZ pairs but not in DZ pairs. Statistical tests suggest a heritability estimate of about 50% that was marginally significantly for SBP and DBP changes during the task. There was no indication of a genetic influence on HR reactivity. Resting level and static task period measures of SBP, DBP, and HR demonstrated statistically significant heritability estimates of 60% to 80%.

Major locus inheritance of apolipoprotein B in Utah pedigrees

A major locus that determines levels of apolipoprotein B (apoB) was revealed by likelihood analysis on 331 members of 36 pedigrees. The major locus explained 43.2% of the observed variance, with the remainder attributed to random environmental factors. Estimated mean apoB levels (mg/dl) were 110.5 +/- 2.5, 141.9 +/- 4.4, and 208.1 +/- 11.5 for low homozygotes, heterozygotes, and high homozygotes, respectively. The corresponding genotypic frequencies were 0.718, 0.259, and 0.023. The apoB locus explained 13% and 14% of the variance in total and low-density-lipoprotein cholesterol levels, respectively. Persons with elevated apoB had normal to high levels of total serum cholesterol and triglyceride and low to normal levels of high-density lipoprotein and apolipoprotein A-I. Sixteen members of three of the pedigrees were heterozygous for familial hypercholesterolemia (FH). Their apoB levels were estimated as 35.72 +/- 7.16 mg/dl above the apoB genotypic means, assuming that the two loci act independently. Therefore, two major loci, the FH locus and the apoB locus, affect two levels, apoB and LDL cholesterol.

The evolution of an effective P & T Committee: advice from the chairman

In an exclusive Hospital Formulary interview, Dr. Roger Williams, Chairman of the University Hospitals P & T Committee, identifies factors that have contributed to the success of their P & T Committee. Policies for evaluating drugs for formulary inclusion, the use and availability of nonformulary drugs, and efforts in improving adverse drug reaction reporting by clinicians are a few of the topics discussed. Dr. Williams' committee supports the concept of a closed, rather rigid formulary, but contends that mechanisms must be available for easy acquisition of nonformulary drugs. Dr. Williams also comments on the clinical benefits derived from participation on a P & T Committee.

A DNA probe for the LDL receptor gene is tightly linked to hypercholesterolemia in a pedigree with early coronary disease

A large, multigenerational family with dominantly inherited hypercholesterolemia was analyzed for genetic linkage between blood levels of low-density lipoprotein (LDL) cholesterol and the locus for the LDL receptor. A genetic marker was identified by restriction fragment length polymorphism (RFLP) in a cloned segment of the LDL receptor gene. We found no exceptions to segregation of the high-LDL cholesterol phenotype with a unique allele at the LDL receptor locus in this pedigree; tight linkage was indicated by a maximum lod score of 7.52 at theta = 0. Knowledge of the LDL receptor genotype will enable investigators to study variability of phenotypic expression in response to environmental influences or to different genetic determinants.

Coronary disease and risk factors in close relatives of Utah women with early coronary death

Familial aggregation of coronary heart disease (CHD) and specific major risk factors were determined among 639 first-degree relatives of 73 women with confirmed coronary death before age 55. They were compared with 1,151 persons in 141 control families. Of women with early coronary death, 62% had first-degree relatives with early coronary disease compared with 12% of affected control family members. In the proband families, coronary incidence rates were 2.7 times the control population rates for women (P<.001) and 1.6 times the control population rates for men (P<.05). An excess incidence of coronary disease was observed for ages 45 to 74 in both men and women.Smoking, hypertension, diagnosed hyperlipidemia and diabetes were all two to three times more common in the female probands with early coronary death than in healthy controls. Hypertension was more common in all proband relatives (both sexes with and without coronary disease). Smoking was more common among female relatives of probands when compared with the controls. These data suggest that early coronary disease in women is often familial and associated with smoking and hypertension. The familial aggregation seems to be stronger in female relatives of female probands with early CHD than in male relatives. Genetic factors or shared family life-style or both likely account for these observations.

Erythrocyte cation transport activities as a function of cell age

Erythrocyte cation transport systems were evaluated on cell fractions from 17 subjects. Density centrifugation was used to separate washed red cells into fractions enriched with younger and older cells; the cell age differences in these fractions were verified by reticulocyte counts (means are 3.5% for younger cell fractions and 0.7% for older cell fractions). Red cell age has a pronounced effect on several cation transport activities. The older cell fractions had increases in lithium-potassium cotransport (p less than 0.001), the rate constant for the lithium-potassium cotransport (p less than 0.001) and cellular cation permeability. The older cells had decreases in the number of ouabain binding sites (p less than 0.001), the rate constant for sodium efflux via the sodium-potassium adenosine triphosphatase pumps (p less than 0.001) and the sodium-lithium countertransport (p less than 0.025). In subjects with markedly different cell ages, these effects should be considered when evaluating red cell cation transport activities.

Evidence for environmental familiality of kallikrein excretion in Utah kindreds

In investigating the role of urinary kallikrein in the pathophysiology of hypertension, we measured 12-hour kallikrein excretion in 1,100 persons in 68 Utah kindreds. The kallikrein excretion was statistically adjusted to account for variations in body size and urine output. Adjusted kallikrein excretion was greater in youths than in adults and correlated with potassium excretion and sodium excretion in persons with normal blood pressure. It was decreased in normotensive subjects with strong family histories of stroke and hypertension, but was not significantly different in adults with hypertension. Adjusted kallikrein excretion was correlated between pairs of siblings, parent-offspring pairs and spouses. Our results indicate that kallikrein excretion is a familial variable, with the familiality due more to shared environmental than genetic factors.

A re-examination of major locus hypotheses for high density lipoprotein cholesterol level using 2,170 persons screened in 55 Utah pedigrees

A dominant major locus (allele frequency of .0025 +/- .0014), resulting in low levels of high density lipoprotein cholesterol (HDL-C), was revealed by likelihood analysis on 2,170 persons in 55 Utah pedigrees. This allele was expressed through HDL-C levels ranging from 20 to 30 mg/dl in seven persons in two pedigrees. Early coronary heart disease was associated with the allele in one pedigree, but not in the other. In the pedigree without associated heart disease, HDL subfractions HDL2 and HDL3 were both low in individuals with the low HDL-C allele. No other major locus determining either high or low levels of HDL-C was identified in our sample. Polygenic heritability as part of the mixed model was estimated as .561 +/- .035.

The genetic determination of plasma apolipoprotein A-I levels measured by radioimmunoassay: a study of high-risk pedigrees

Apolipoprotein A-I (apo A-I) is the major protein component of the high-density lipoprotein (HDL) found in all primates. Using radioimmunoassay, we measured plasma apo A-I levels in 97 individuals from 23 pedigrees ascertained through cases of hypertension or early coronary artery disease (CAD). Using complex segregation analysis, we found that a genetic model with both a single locus with a major effect and polygenic loci gave the best explanation for the distribution of apo A-I levels in these pedigrees. There was no evidence for a major locus effect on HDL cholesterol in these pedigrees. This is the first study to show evidence of a major effect of a single genetic locus on the quantitative variation of plasma apo A-I in a sample of pedigrees enriched for individuals at risk for CAD.

Innovative blood pressure measurements yield information not reflected by sitting measurements

A study of 873 healthy adults and children from Utah kindreds was performed to identify redundant and unique information contained in multiple diverse blood pressure determinations. Systolic blood pressure, fourth-phase and fifth-phase diastolic blood pressures, and simultaneous heart rates were measured in subjects sitting, standing, supine, and tilting, during half-maximal handgrip exercise, and just before blood drawing. A correlation matrix of 57 blood pressure and pulse variables in 618 healthy adults was analyzed. Factor analysis of the correlation matrix showed that all systolic blood pressures loaded as a single factor, accounting for 44% of the total variance of the observed variables. All heart rates also loaded together as a single factor. Diastolic blood pressures showed much more heterogeneity of information distributed among five separate factors. The same basic factors were found in young adults (age, 18-35 years) and older adults (age, 36 + years). Children under 12 years of age showed very different factor patterns, and youths 12 to 17 years of age showed patterns intermediate between those of adults and children. In light of recent clinical trials, better definitions are being sought for hypertension. Information from blood pressures other than sitting determinations may improve the definition of hypertension or better predict which patients have the highest risk of hypertension and its cardiovascular complications.

Factor analysis suggesting contrasting determinants for different blood pressure measurements

A multiple regression analysis was performed on statistically independent factors derived from blood pressure measurements and possible predictive variables in 618 Utah adults. Nine blood pressure factors obtained in a previous study composed the dependent variables; 35 anthropometric, questionnaire, and biochemical variables were reduced by factor analysis to 10 factors and used as independent variables. Body size and obesity had significant independent effects on different types of blood pressure: body size correlated most highly with systolic blood pressure, while obesity correlated most highly with sitting diastolic blood pressure measurements. Smoking did not correlate with sitting blood pressure but did show a significant positive correlation (after controlling for obesity) with tilt and supine diastolic pressure. Alcohol consumption correlated positively with sitting diastolic pressure when the effects of body size and obesity were controlled. No correlations were found between urinary potassium or sodium excretion and any blood pressure factors, but a significant positive correlation was seen between plasma sodium concentration and several different types of diastolic blood pressure measurements. Psychological stress showed a significant independent positive correlation with systolic blood pressure measurements that was strongest in adults over 35 years of age. The multiple correlation values for the multiple regression equations ranged from 0.19 to 0.52.

Identification and relative weight of cardiovascular risk factors

Basic concepts of epidemiology are presented with an update on the more than 270 factors that the authors have found suggested as contributors to cardiovascular disease risk. A comprehensive classification scheme and public health and clinical implications are discussed. Based on predictions from prospective and intervention studies, up to 90 per cent of coronary heart disease could be prevented by optimization of known cardiovascular risk factors.

Evidence that men with familial hypercholesterolemia can avoid early coronary death. An analysis of 77 gene carriers in four Utah pedigrees

To study the genetic influence on serum cholesterol levels and early coronary heart disease, 1,134 individuals were screened from 18 Utah pedigrees. In most pedigrees, serum cholesterol appeared to be a purely polygenic trait, with 54% heritability. In four pedigrees with dominant familial hypercholesterolemia, male heterozygotes had a mean serum cholesterol level of 352 mg/dL, myocardial infarction at an average age of 42 years, and coronary death at an average age of 45 years. An informative pedigree structure allowed the identification of four ancestral males born before 1880 who carried this lethal gene and survived to ages 62, 68, 72, and 81 years. This suggests that some healthy life-style factors protected these men against the expression of a gene that has led to coronary disease by age 45 years in all of their heterozygous great-grandsons. One heterozygote showed a drop in serum cholesterol level from 426 to 248 mg/dL, with strict adherence to a low-fat diet without drugs. These observations should help encourage physicians to try harder to identify and help such individuals.

Testing for familial aggregation of a dichotomous trait

Familial aggregation of a disease is usually tested using a chi square statistic on a sample of pairs of related individuals. Standard sampling designs often produce dependent observations (multiple pairs from the same family), possibly inflating the numerical value of the statistic over the value independent observations would produce. This article presents a derivation of the chi square statistic for familial aggregation, allowing for dependency because of the inclusion of the same and related persons in multiple pairs. For intraclass aggregation, the standard chi square statistic is appropriate. For interclass aggregation, an adjustment to the standard chi square statistic is needed; the adjustment depends on the disease frequency and the intraclass aggregation within each class.

A comparison of positive family history definitions for defining risk of future disease

The relative risk of developing future coronary heart disease (CHD) or hypertension between positive and negative family history families is compared for different definitions of a positive family history when applied to life-table data for 94,292 persons. Having two or more first degree relatives with CHD identifies 8% of the population with relative risks of 3.3-5.9 for CHD before age 50. A quantitative family history score (FHS) compares the family's age and sex specific disease incidence to that expected in the general population and predicts future disease incidence in unaffected family members slightly better (relative risks = 3.4-6.9 for CHD before age 50). Using only one affected relative, even if affected at an early age (less than 55 years old) does not discriminate low and high risk families as well (relative risks = 1.4-3.9 for CHD before age 50). Similar results were obtained for family history of hypertension. There is an increase in future disease incidence for all ages with increasing FHS values (p less than 0.0001), which can be used as a continuous or categorical variable in analysis where family history is associated with a particular variable under study. These results provide a rational basis for choosing and applying specific definitions of a positive family history of coronary disease or hypertension in clinical, epidemiologic and genetic studies.

Associations of three erythrocyte cation transport systems with plasma lipids in Utah subjects

To investigate the pathophysiology of essential hypertension, detailed biochemical and clinical variables were collected and analyzed for 2091 Utah subjects aged 3 to 83 years. Three different measurements of erythrocyte cation transport were obtained: Na+-Li+ countertransport, Li+-K+ cotransport, and furosemide-insensitive Li+ efflux into MgCl2. Total plasma cholesterol, triglycerides, and high density lipoprotein cholesterol levels were obtained from fasting subjects. Levels of high density lipoprotein subfractions 2 and 3 were also obtained from 350 subjects. Standardized data collection also included blood pressure, height, weight, and presence or absence of a diagnosis or treatment of essential hypertension. In univariate analyses of all 1420 adults, each of the three transport systems showed the same significant correlations with triglyceride levels (r = 0.33-0.35, p less than 0.0001), high density lipoprotein concentration (r = -0.19 to -0.21, p less than 0.001), and weight (r = 0.22-0.28, p less than 0.0001). In multivariate regression analyses, values for each transport system were significantly higher in hypertensive subjects; values for triglycerides, high density lipoprotein, and usually, the high density lipoprotein subfractions continued to have strong significant independent associations with all three transport systems; and weight remained significantly related only to Na+-Li+ countertransport. In separate logistic regressions, plasma triglyceride levels (positively, p less than 0.001) and high density lipoprotein subfraction 3 levels (inversely, p less than 0.03) were associated with hypertension itself. In multivariate analyses among 671 children, high density lipoprotein and high density lipoprotein subfraction 3 levels showed significant (p less than 0.05) inverse correlations with Na+-Li+ countertransport and furosemide-insensitive Li+ efflux.(ABSTRACT TRUNCATED AT 250 WORDS)

Preventing coronary heart disease in high-risk families

A preventive nursing intervention to reduce coronary heart disease (CHD) risk was tested. The sample was 19 families composed of 58 first-degreed relatives of young (age 30-55 years) victims of sudden cardiac death. Families were randomly assigned to control and experimental groups. The intervention at 3-5 months postdeath focused on assessment of health history, health behaviors, health beliefs, informing and educating about CHD risk factors, and methods for detecting and reducing these factors. The control group received mailed questionnaires and no intervention. The subject's reduction of CHD risk was measured at 7 months by changes in high risk CHD behaviors, changes in health beliefs, and adherence to screening for serum cholesterol and blood pressure determination. Analysis of covariance (covarying age and pretest scores) demonstrated no differences between groups for health beliefs; however, significant differences for health beliefs existed between the sibling subgroups. The intervention was correlated with a significant reduction in alcohol intake. Reductions in high fat meat consumption were in the desired direction. Greater percentages of subjects in the intervention group obtained blood pressure and cholesterol screening.

The goals and functions of a P & T committee

The goals and functions of a productive and effective University Hospital P & T Committee are described. The primary responsibilities of the P & T Committee are to ensure high-quality drug therapy for hospital patients, provide liaison between the medical staff and the department of pharmacy services, and advise the Institutional Review Board of the University on the study of investigational drugs in humans. To meet its responsibilities, the P & T Committee maintains a formulary of medications approved for routine patient care, reviews drug use and adverse drug reactions, and establishes procedures for prescribing, dispensing,and administering drugs in the hospital. The P & T Committee acts on behalf of the Medical Board of the hospital, and actions of the Committee are subject to the Board's approval.

Cost containment of the second-generation cephalosporins by prospective monitoring at a community teaching hospital

All patients receiving cefoxitin and cefamandole were prospectively reviewed for appropriate and inappropriate utilization. There were two eight-week survey periods. In period 1, 81 (70%) of 115 patients received cefoxitin appropriately and six (40%) of 15 patients received cefamandole appropriately. In patients receiving antibiotics inappropriately, 12 (35%) of the 34 receiving cefoxitin and eight (89%) of the nine receiving cefamandole had infections that could have been treated with less expensive, equally efficacious antibiotics. Changes in antibiotic therapy were made in 79% of patients based on our recommendations. The estimated annual cost saving for these antibiotics was $40,290. During period 2, 73 (91%) of 80 patients were given cefoxitin appropriately and 14 (61%) of 23 patients received cefamandole appropriately. Forty-three percent of those receiving cefoxitin and 33% of those receiving cefamandole inappropriately could have been treated with a less expensive, equally efficacious antibiotic. In 88% of patients, the attending physicians followed our recommendations.

Urinary kallikrein: assay validation and physiological variability

Decreased urinary kallikrein (UK) output has been suggested as a preclinical indicator of essential hypertension. In preparation for UK studies in hypertension prone Utah kindreds, we assessed selected UK assay parameters and physiological variability. Precision for the colorimetric kallikrein assay was quite acceptable, coefficient of variation (CV) less than 5% within run and 14% day-to-day at a concentration of 9.5 TU/l. The mean recovery was 105% and assay results were correlated with results from the 3H-TAME esterase method, r = 0.990. Urine specimens were stable at room temperature for up to 4 days, frozen at -20 degrees C for 6 weeks, or frozen at -80 degrees C after Sephadex treatment for a year. UK output varied significantly throughout the day with excretion highest in the morning. Urine collections at 10.00, 12.00 and 14.00 had significantly (p less than 0.05) more UK than the overnight collection. Intra- and inter-individual variations were of the same magnitude, mean 20%. In children UK output increased with age until the adult levels were reached at age 15. Male and female values were similar. Smoking; consumption of alcohol, coffee, tea, cola of chocolate; and female hormone medications did not significantly influence the 12-hour UK output in the 1110 caucasian subjects.

Pregnancy in carriers of high-affinity hemoglobins

Pregnancy in female carriers of abnormal hemoglobins with great avidity for oxygen provides a unique opportunity to assess the importance of the usual difference in oxygen affinity between fetal and maternal blood. Outcome of pregnancy was recorded for carriers of hemoglobins Bethesda, Osler, and Yakima, whose p50s (9.5, 9.1, and 12 mm Hg at pH 7.4) were far lower than that of a normal fetus (23 mm Hg at pH 7.3). Neither spontaneous abortions nor intrauterine growth retardation could be attributed to the presence of high oxygen affinity in the mothers. In vitro simulations suggested that neither maternal or fetal polycythemia alone was sufficient to adjust for perturbation of the normal situation, and increased uterine and/or fetal blood flow probably provided additional compensation.

Effects of age, sex, and body habitus on QRS and ST-T potential maps of 1100 normal subjects

Body surface potential maps provide more detailed regional cardiac electrophysiologic information than the standard electrocardiogram. We performed a large-scale study of a normal population to form a comparison base for evaluation of the clinical utility of this technique. We analyzed body surface maps from 1113 normal subjects from 10 to 80 years old to detail map features as a function of age, sex, and body habitus. Maps were analyzed by visual inspection and by a spatial and temporal data reduction technique that allows statistical comparison of map features. On average, both QRS and ST-T potentials decreased with increasing age. Potential pattern distributions remained constant from 10 to 40 years. Beyond age 40, larger numbers of maps from normal subjects showed depolarization patterns consistent with delayed activation of the left anterior fasicle, despite normal 12-lead electrocardiograms. Only minor QRS potential amplitude and distribution differences were noted when male and female subjects were compared within groups of similar age and body habitus. Male subjects consistently showed greater average T potential amplitudes. Slender body habitus was associated with a more horizontal "zero" potential line. In female subjects over age 40 there were more extensive low-level negative potentials recorded over the precordium during the ST segment than in men. This study defines the range of normal body surface potential maps in a large clinically normal population and provides a basis for qualitative and statistical comparison with map features of patients with disease.

Effects of household sharing on high density lipoprotein and its subfractions

Household effects accounted for significant proportions of the observed variance of high density lipoprotein cholesterol (HDL-C) and subfractions HDL2 and HDL3. It was found that 19.3% of HDL-C variance could be attributed to a juvenile sib effect (under age 18); 17.4% of HDL2 variance could be attributed to a sib effect (of any age); and 22.1% and 32.6% of the HDL3 variance could be attributed to a parent-offspring effect and a sib effect (of any age), respectively. In addition, additive genetic effects accounted for 56.5%, 37.3%, and 28.3% of the variances of HDL-C, HDL2, and HDL3, respectively. These are maximum likelihood estimates obtained using a variance components model on 2,149 HDL-C levels measured on members of 54 Utah pedigrees, and 337 HDL2 and HDL3 levels measured on a subset of 14 pedigrees.

Heritability of cardiac size: an echocardiographic and electrocardiographic study of monozygotic and dizygotic twins

Because of the uncertainty as to the extent to which cardiac size is determined by exercise training vs genetic endowment, this study investigated familial (genetic plus common family environment) vs nonfamilial influences on cardiac size. College-age monozygotic twins (group 1, 31 sets), dizygotic twins (group 2, 10 sets), siblings of like sex (group 3, six sets), and nonrelated subjects (group 4, 15 sets) underwent echocardiographic and electrocardiographic tests, measurement of maximum oxygen uptake (VO2max), and evaluation of pulmonary and body composition; mean intrapair differences of the four groups were compared. Mean intrapair differences in cardiac size varied as much for subjects in group 1 as for those in groups 2 and 3. However, subjects in groups 1, 2, and 3 had less variation (p less than .05) than those in group 4. After the initial testing, 14 pairs of monozygotic twins, five sets of dizygotic twins, and six sets of siblings underwent 14 weeks of exercise training (both members participated) and all tests were repeated. After exercise training, subjects in group 1 still had as much intrapair variability in cardiac size as those in groups 2 and 3. The data suggest cultural familial influences are more important in determining cardiac size than nonfamilial influences or even genetic influences alone.

The relationship of lithium-potassium cotransport and the passive lithium leak to hypertension in Utah subjects

Rate constants for lithium-potassium cotransport (kLPC) and the lithium efflux into MgCl2 with furosemide (passive lithium leak) along with sodium-lithium countertransport (SLC) were measured in erythrocytes from 351 normotensive adults age 18 and over, 220 youth under age 18 and in 27 hypertensives. The kLPC was significantly higher in the hypertensives than the adult normotensives with means and standard deviations of 13.9 +/- 9.2 vs. 8.7 +/- 5.9 10(-3)/hr (p less than 0.01). Adjusting for the significant weight (p = 0.014) and sex (p = 0.066, normotensive males higher than females) associations with kLPC in an analysis of covariance, increased the significant difference between the hypertensives and normotensives (p = 0.0004). The passive lithium leak rate constant was also higher in hypertensives than normotensives (20.2 +/- 7.6 vs. 15.5 +/- 5.3 10(-3)/hr, p less than 0.01). Weight (p=0.0003), but not sex, was related to the leak but did not account for the difference between hypertensives and normotensives (p = 0.0009). Mean blood pressure was positively associated with the lithium leak but not the kLPC or SLC values in a multivariate regression.

Understanding genetic and environmental risk factors in susceptible persons

Most major chronic diseases probably result from environmental factors accumulating over time in genetically susceptible persons. A detailed family history assessment can help identify the subset of the general population with a strong predisposition to certain major diseases. An understanding of the environmental factors promoting disease development will facilitate more effective prevention or delay disease in a targeted susceptible population. To effectively use this growing knowledge in genetics and epidemiology, health professionals need to motivate people to follow sound recommendations for preventing and delaying disease.To increase the efficiency and effectiveness of strategies for health promotion and disease prevention, family history data can help determine those diseases for which persons have the greatest risk. They can then concentrate their primary efforts on those preventive measures that will most likely benefit them.

Hemodialysis does not affect erythrocyte sodium-lithium countertransport

Sodium-lithium countertransport measurements on erythrocytes are currently of interest because some hypertensive subjects and their relatives have abnormally high values. Woods et al [1] reported that red cells taken from dialysis patients after hemodialysis had significantly lower sodium-lithium countertransport than before dialysis. They suggested that sodium-lithium countertransport is influenced by 'a dialyzable plasma factor'. We conducted experiments to further evaluate their observations relating to the 'dialyzable plasma factor'. However, we have been unable to confirm their findings. Neither an effect of hemodialysis on sodium-lithium countertransport in erythrocytes from maintenance dialysis patients nor any effect of dialysis on normal erythrocytes in vitro was evident. Our results do not support the existence of a dialyzable plasma factor affecting sodium-lithium countertransport.

The treatment of myopia with atropine and bifocals. A long-term prospective study

Two hundred fifty-three patients were followed for up to nine years (mean, 4 1/4 years). They were on a regimen of atropine 1% once a day in an attempt to retard myopic progression. Their rate of myopic progression prior to atropine treatment was compared with 146 controls. The rates of myopic progression during and after treatment were also compared to those of the controls. The results from several analyses showed a marked flattening in the rate of myopic progression during treatment, and the rate of myopic progression after treatment ran parallel to those in the control group. Age in relation to myopic progression was evaluated in subgroups. A variation existed in the rate of myopic progression in the controls. The fastest rate of myopic progression occurred between eight and 12 years of age, and the slowest rate of myopic progression developed in those patients over 18 years of age.

Magnified risks from cigarette smoking for coronary prone families in Utah

The contribution of currently accepted risk factors to the familiality of early coronary heart disease (CHD) is poorly understood. In a telephone and mail survey, risk factor and disease morbidity and mortality data were collected from 100 proband and 185 control families encompassing about 40,000 person-years of experience. Probands were white married men who had died of CHD by age 45. There was a threefold increase in CHD incidence among first-degree relatives of probands compared with control families. In all, 67% of probands had at least one first-degree relative with early CHD, and 29% had two or more first-degree relatives with early CHD compared with 8% of the control families with two or more cases of early CHD. The most striking new finding of this study is the apparently magnified liability of cigarette smoking in families prone to have early coronary heart disease. This effect was seen strongly at younger ages (under 50). Furthermore, in about a third of all families with a history of early CHD, smoking seemed to be the only risk factor contributing to the familial occurrence of the disease. The findings show a large excess absolute risk for CHD among smoking members of proband families and further suggest a possibly heritable susceptibility to the deleterious effects of smoking in many families prone to early coronary disease. Modification of coronary risk factors, especially cigarette smoking, would be of greatest benefit among members of high-risk families.