Associations between classical cardiovascular risk factors and coronary artery disease in two countries at contrasting risk for myocardial infarction: the PRIME study

Metabolically Unhealthy Normal Weight: Prevalence and Associated Factors in an Adult Population from Northwest Colombia

Background and Aim

Individuals with a normal weight may have metabolic alterations at risk for chronic non-communicable diseases. The prevalence of this condition and associated factors have not been reported in Latin American populations. We aimed to estimate the presence and associated factors of Metabolically Unhealthy Normal Weight (MUNW) in adults from a public program for the control and prevention of chronic diseases in Medellín, Colombia.

Methods

Cross-sectional study. Overweight and normal weight were characterized according to the absence or presence of one or more components of the metabolic syndrome, obtaining four phenotypes: Metabolically Healthy Normal Weight (MHNW), MUNW (phenotype of interest), Metabolically Healthy Overweight (MHO), and Metabolically Unhealthy Overweight (MUO). The association of these phenotypes with sociodemographic variables of lifestyles and increased waist circumference was conducted by using logistic regression.

Results

In 37,558 individuals (72.7% women), the prevalence of MUNW was 23.3%. Among the additional phenotypes, MUO was found to be more prevalent (71.6%), while MHNW and MHO were very slightly common, 2% and 3.1%, respectively. In a multiple model, the factors associated with MUNW were age over 60 years (trend [OR 1.56 95% CI 0.97-2.52] p-value = 0.066), living in a rural area ([OR 1.58 95% CI 1.09-2.29] p-value = 0.015), and increased waist circumference ([OR 1.68 95% CI 1.45-1.95] p-value < 0.001). Male gender was inversely associated with all phenotypes (P < 0.05).

Conclusion

Almost a quarter of the analyzed population presented MUNW. People living in a rural area and over 60 years old were more likely to present MUNW. Men were less likely to present the weight phenotypes studied, although they could have been underrepresented.

Should your family history of coronary heart disease scare you?

Traditional risk factors explain most of the risk associated with coronary heart disease, and after adjustment for risk factors family history was believed to contribute very little to population-attributable risk of coronary heart disease. However, the INTERHEART study demonstrated an independent association of family history of coronary heart disease with acute myocardial infarction. To assess this relationship more comprehensively in multiple datasets in different populations, we carried out a detailed review of the available evidence. Case-control studies involving 17,202 cases and 30,088 controls yielded a pooled unadjusted odds ratio (random-effects model, overall I(2) = 64.6%, P = 0.000) of 2.03 (95% confidence interval: 1.79-2.30), whereas cohort studies that included 313,837 individuals yielded an unadjusted relative risk for future coronary heart disease (random-effects model, overall I(2) = 88.7%, P = 0.000) of 1.60 (95% confidence interval: 1.44-1.77). Although the presence of family history of coronary heart disease indicates a cumulative exposure of shared genes and environment, the risk estimates for family history did not attenuate significantly after adjustment for conventional coronary heart disease risk factors in several studies. It is probably an oversimplification to dichotomize the family history variable into a simple "yes" or "no" risk factor, as the significance of family history is influenced by several variables, such as age, sex, number of relatives, and age at onset of disease in the relatives. Moreover, a quantitative risk-assessment model for the family history variable, such as the "family risk score," has a positive linear relationship with coronary heart disease. More studies are warranted to assess the benefits and risks of intensive interventions, both targeted individually and at the family level, among individuals with a valid family history and borderline elevated risk factors.

A review of family history of cardiovascular disease: risk factor and research tool

Family history (FH) studies have been used to quantify the heritable component of diseases for centuries. Genome-wide association studies (GWAS) in both coronary artery disease (CAD) and stroke have implicated several gene loci in these diseases and have shed light on biological mechanisms, but have not yet yielded fruit in terms of clinical application, partly because of the complexity of gene-gene and gene-environment interactions. Family history studies remain the most accessible way of measuring the inherited component of a disease and they represent the overall interaction between environmental and genetic factors. The current knowledge base for FH of stroke and CAD and disease correlates are evaluated. FH of stroke and CAD are inconsistently recorded in clinical practice, partly because of lack of data regarding family history of stroke and CAD in prospective population studies. Future FH studies are necessary to characterise the role of FH in prognosis and risk prediction of contemporary populations, but also to guide future studies of genetics and epigenetics. In this article, the study design and methodology of family history studies are reviewed. The Oxford Vascular Study (OXVASC) is an ongoing prospective, population-based study of CAD and stroke with very high levels of clinical ascertainment, which allows detailed study of FH, and has already shown important new findings. Such data may help to formulate improved risk prediction tools and to inform future GWAS.

High risk for sleep apnea in the Berlin questionnaire and coronary artery disease

INTRODUCTION

Obstructive sleep apnea (OSA) affects up to 30% of the adult population and is a risk factor for coronary artery disease (CAD). The diagnostic process, involving polysomnography, may be complex. Berlin questionnaire (BQ) is a validated and economical screening tool.

PURPOSE

The aim of this study was to assess the performance of the BQ for the diagnosis of OSA in individuals with angina complaints.

METHODS

Patients undergoing diagnostic cineangiography, portable type III polysomnography to determine the apnea-hypopnea index (AHI), and who answered the BQ were included. We excluded patients older than 65 years that were smokers, diabetics, and morbidly obese. High risk for OSA was based on positive responses in two of three symptom criteria of the BQ. CAD was defined by the presence of >50% lesion in coronary arteries.

RESULTS

In 57 included cases, high risk in the BQ indicates significant odds ratio [95% confidence interval] for the presence of CAD (4.5[1.03-19.25], P = 0.045), adjusted for usual confounders: gender, age, and body mass index. The sensitivity and the specificity of BQ for CAD were 70% and 48%, respectively; the positive and negative predictive values are 56% and 64%.

CONCLUSIONS

In conclusion, simple questionnaire-based diagnostic tools can be included in the screening procedures of patients with angina to detect the need for further OSA evaluation. In conclusion, the BQ is an effective instrument for this purpose.

Sex-Specific Familial Clustering of Myocardial Infarction in Patients With Acute Coronary Syndromes

Background— Family history of premature myocardial infarction (MI) in first-degree relatives is a risk factor for MI and an indication for primary prevention. Although excess mother-to-daughter “transmission” occurs in ischemic stroke, no published studies have considered sex-of-parent/sex-of-proband interactions in the heritability of MI.

Methods and Results— In a population-based study (Oxford Vascular Study) of all patients with acute coronary syndromes (ACS), irrespective of age, family history of all acute vascular events and related risk factors were analyzed by sex and age of both probands and first-degree relatives. Premature events were categorized as occurring at age <65 years. Of 835 probands with 1 or more ACS, 623 (420 men) had incident events and complete family history data. In probands with premature ACS, maternal history of both MI and of all vascular events were more common in female than male probands (odds ratio [OR], 2.25; 95% CI, 1.02 to 4.94; P =0.04 and OR, 3.03; 95% CI, 1.47 to 6.26; P =0.002, respectively). No such effect existed for paternal history (OR, 1.00; 95% CI, 0.46 to 2.10; P =0.99 and OR, 1.19; 95% CI, 0.58 to 2.43; P =0.63, respectively). Age at ACS in probands was highly correlated with age at MI in mothers ( r =0.46, P <0.001), regardless of the proband’s sex. Consequently, history of premature maternal MI was strongly associated with premature ACS and premature MI in female (OR, 10.52; 95% CI, 2.17 to 56.6; P =0.001 and OR, 7.31; 95% CI, 1.55 to 34.6; P =0.004, respectively) and male probands (OR, 3.88; 95% CI, 1.20 to 12.6; P =0.01 and OR, 3.63; 95% CI, 1.13 to 11.60; P =0.02, respectively).

Conclusions— Important sex-of-parent/sex-of-proband interactions exist in the family history of MI in patients with ACS. Greater emphasis should be placed on maternal than paternal history of MI, particularly in women aged <65 years.

Residential environment and blood pressure in the PRIME Study: is the association mediated by body mass index and waist circumference?

OBJECTIVES

Few studies have examined whether social characteristics of the residential environment are associated with blood pressure after controlling for individual sociodemographic characteristics. Even less is known about the processes by which these associations operate. Therefore, we examined whether distinct dimensions of the residential environment (socioeconomic position and urbanicity) were associated with systolic blood pressure. To better understand the processes involved in the associations between contextual factors and blood pressure, we assessed the extent to which these associations were mediated by body mass index and waist circumference.

METHODS

We analysed data from the PRIME Study (7850, 50-60-year-old men surveyed in 1991-1993 in three French regions and recently geocoded on a local scale). We used multilevel regression models to estimate associations between contextual factors and blood pressure, and path analysis to investigate possible mediators of these associations.

RESULTS

After adjustment for individual socioeconomic variables, systolic blood pressure increased independently with decreasing municipality population density and decreasing neighbourhood educational level. Path analysis indicated that approximately 37% of the association between neighbourhood education and blood pressure was statistically explained by the heavier weight and stronger central adiposity of people from deprived neighbourhoods. Approximately 19% of the association with population density was mediated by anthropometric factors.

CONCLUSIONS

These data suggest that the neighbourhood environment may influence blood pressure; only part of the associations between contextual factors and blood pressure may operate through body weight and body shape modification.

Increased concentrations of C-reactive protein and IL-6 but not IL-18 are independently associated with incident coronary events in middle-aged men and women: results from the MONICA/KORA Augsburg case-cohort study, 1984-2002

OBJECTIVE

We performed a prospective case-cohort study in initially healthy, middle-aged men and women from the MONICA/KORA Augsburg studies conducted between 1984 and 2002 to assess the role of IL-18 in comparison with IL-6 and CRP in the prediction of incident coronary heart disease (CHD).

METHODS AND RESULTS

Concentrations of IL-18 were measured in 382 case subjects with incident CHD and 1980 noncases. Mean follow-up was 11 years. Baseline concentrations of IL-18 were slightly higher in cases than in noncases (172.4 [1.0] versus 161.3 [1.0] pg/mL, respectively; P=0.114), but were clearly elevated for C-reactive protein (CRP) and IL-6 in cases compared with noncases. In multivariable analyses, accounting for classical cardiovascular risk factors and inflammatory markers, no statistically significant association was seen between increased concentrations of IL-18 and incident CHD both in men (hazard ratio [HR] and 95% confidence intervals [CIs] comparing extreme tertiles, 1.20; 95% CI, 0.85 to 1.69), and in women (HR, 1.25; 95% CI, 0.67 to 2.34). However, in this population increased concentrations of CRP and IL-6 were found to be independent predictors of future CHD events, even after multivariable adjustment.

CONCLUSIONS

Elevated concentrations of CRP and IL-6, but not IL-18, were independently associated with risk of CHD in subjects from an area with moderate absolute risk.

Family history, longevity, and risk of coronary heart disease: the PRIME Study

BACKGROUND

To assess the contribution of family history of coronary heart disease (CHD) and longevity in parents to 5-year incidence of coronary events in middle-aged men.

METHODS

A prospective study in men from Northern Ireland and the French cities and environs of Lille, Strasbourg, and Toulouse. A total of 10 600 men aged 50-59 years were examined between 1991 and 1994 and followed annually by questionnaire for incident cases of coronary disease. A detailed family history was taken and a quantitative family risk score for CHD was calculated for each subject. Five-year follow-up is complete; all coronary events (coronary deaths, myocardial infarction, and angina) documented by clinical records were reviewed by an independent medical committee.

RESULTS

At screening, 9758 subjects were free of clinical and historical evidence of CHD; in this group there were 317 coronary events by 5 years of follow-up. Subjects whose parents had both survived until >/=80 years showed a relative odds of 0.49 (95% CI: 0.31-0.77) for risk of a coronary event compared with subjects whose parents had not survived until >/=80 years old with adjustment for age and nine other risk factors including family history. The pattern of results was similar in France and Northern Ireland, although parental survival was longer in France. Likewise, subjects with a strong family history showed a relative odds of 1.93 (95% CI: 1.25-3.00) compared with subjects without such a history, after adjustment for age and the nine risk factors including parental longevity. The pattern of results was similar in France and Northern Ireland.

CONCLUSIONS

These results indicate that a family history of coronary disease and parental longevity, although related, act independently of one another and of other major cardiovascular risk factors in predicting 5-year risk of subsequent coronary events.

Physical activity and coronary event incidence in Northern Ireland and France: the Prospective Epidemiological Study of Myocardial Infarction (PRIME)

BACKGROUND

The influence of physical activity on the incidence of angina pectoris and hard coronary events (myocardial infarction and coronary deaths) was examined in Northern Ireland and France at contrasting risk for coronary heart disease (CHD) and with different physical activity patterns.

METHODS AND RESULTS

Participants of the Prospective Epidemiological Study of Myocardial Infarction (PRIME) (n=9758; age, 50 to 59 years), free of CHD at baseline, were followed up for 5 years: 167 hard CHD and 154 angina events were recorded. Net energy expenditure (EE) as the result of physical activity was assessed by means of the MONICA Optional Study of Physical Activity Questionnaire (MOSPA-Q). Leisure-time physical activity EE was calculated; subjects were also categorized as to whether they performed high-intensity leisure-time activities or walked or cycled to work. After multivariate adjustment, leisure-time physical activity EE was associated with a lower risk of hard CHD events (P<0.04), whereas walking or cycling to work was not independently related to hard CHD events. No interaction by country was found. The beneficial effect of leisure-time physical activity was also present among subjects who did not report high-intensity activities (P<0.04), with similar results in France and Northern Ireland. In contrast, an increasing level of leisure-time physical activity was associated with a higher risk of angina in both countries.

CONCLUSIONS

These data indicate a beneficial effect of leisure-time physical activity EE on hard CHD incidence in middle-aged men, which could partly explain the unfavorable rate of CHD in Northern Ireland. The higher level of leisure-time activities in France could, in part, explain its lower rate of CHD.