Predictors of atherosclerosis in the Honolulu Heart Program. I. Biologic, dietary, and lifestyle characteristics

Effects of smoking on central blood pressure and pressure amplification in hypertension of the young

The aim of this study was to investigate the effect of cigarette smoking on peripheral and central blood pressure (BP) in a group of young stage I hypertensives. A total of 344 untreated subjects from the HARVEST study were examined (mean age 37±10 years). Patients were divided into three groups based on smoking status: non-smokers, light smokers (⩽5 cigarettes/day) and moderate-to-heavy smokers (>5 cigarettes/day); and into three groups by age: 18–29, 30–39 and ⩾40 years. Central BP measurements and augmentation index (AIx) were calculated from brachial pressure waveform, with applanation tonometry, by means of the Specaway DAT System plus a Millar tonometer. The central waveform was derived from peripheral BP using the same software system of the SphygmoCor System pulse wave analysis. In addition, two indirect measurements of arterial stiffness were calculated: pulse pressure (PP) and systolic BP amplification. Central systolic BP and PP were higher in smokers than in non-smokers (systolic BP: 121.9±13.1 mmHg in non-smokers, 127.2±16.5 mmHg in light smokers, 126.7±15.3 mmHg in those who smoked >5 cigarettes/day, p=0.009; PP: 37.7±9.8 mmHg, 41.5±13.1 mmHg, 41.9±10.5 mmHg, respectively, p=0.005). Lower systolic BP amplification ( p<0.001) and PP amplification ( p=0.001) were observed in smokers compared to non-smokers. In a two-way ANCOVA analysis, systolic BP amplification markedly declined across the three age groups ( p=0.0002) and from non-smokers to smokers ( p=0.0001), with a significant interaction between smoking and age group ( p=0.05). The AIx was higher in smokers compared to non-smokers ( p=0.024). In young hypertensives, smoking has a detrimental effect on central BP, accelerating the age-related decline in BP amplification.

Improvement of cardiovascular risk prediction using coronary imaging: subclinical atherosclerosis: the memory of lifetime risk factor exposure

Deaths from diseases of the heart are decreasing. Cardiovascular diseases (CVD) will be the main cause of morbidity and mortality in 2015 according to a WHO report. The main problem is related to the long-time delay between the start of the development of atherosclerosis in young adults and the manifestation many decades later. Despite a recent decline in a CVD mortality rate in men and women, the main problem is related to the acute manifestation as the acute coronary syndrome, which leads 30-50% of subjects to sudden and fatal outcomes. In addition, about 20% of first and recurrent acute myocardial infarctions are silent. The lifetime risk of coronary artery disease after 40 years is 49% for men and 32% for women. That means, we are confronted with a major health care problem. This is even more obvious, when the rate of coronary heart disease deaths out of the hospital are taken into account which amount to 70% in 2007. These data are confirmed for Europe despite a strong decline of hospital deaths. Another problem is related to the fact that the number of sudden cardiac death amounts to >300 000 in the general US population. It is about 10 times higher than in those patients who are defined as prone to sudden death due to low ejection fraction, ventricular arrhythmias, and acute myocardial infarction. For cardiologists, this general topic becomes even more obvious, because even well-known cardiologists experienced early (≤65 years) sudden cardiac deaths such as RW Campbell, JM Isner, PA Poole-Wilson, H Drexler, and recently the paediatric cardiologist from Hannover, A Wessels. These events underline again what has been emphasized 15 years ago by the MONICA study that two-thirds of patients die outside the hospital and that we have to concentrate on primary and secondary prevention, also in memory of these colleagues. This review will demonstrate the potential value of coronary artery calcification screening which can be used as a sign of subclinical coronary arteriosclerosis for improved risk prediction, the first step to prevention. Subclinical atherosclerosis represents the vessel memory of risk factor exposure.

The prevalence of aortic calcification in Japanese compared to white and Japanese-American middle-aged men is confounded by the amount of cigarette smoking

BACKGROUND

The prevalence of coronary artery calcification (CAC) in Japanese men is lower than in white and Japanese-American men. It is unclear if aortic calcification (AC) strongly linked to smoking is also lower in Japanese men who have many times higher smoking prevalence compared to US men.

METHODS

We conducted a population-based study of 903 randomly-selected men aged 40-49 years: 310 Japanese men in Kusatsu, Japan, 301 white men in Allegheny County, US, and 292 Japanese men in Hawaii, US (2002-2006). The presence of AC was assessed by electron-beam tomography. AC was defined as Agatston aortic calcium scores (AoCaS) >0 and ≥ 100.

RESULTS

Japanese (35.8%) had significantly less AoCaS>0 compared to both white (68.8%, p<0.001) and Japanese-American (62.3%, p<0.001) but similar AoCaS ≥ 100 (19.4%, 18.3%, 22.6%, respectively, p=0.392). The pack-years of smoking, which was highest in Japanese, was the most important single associate of AC in all populations. Additionally age, low-density-lipoprotein cholesterol (LDL-C), and triglycerides in Japanese; body-mass index (BMI) in white; and BMI, LDL-C, hypertension, diabetes, and lipid medications in Japanese-American were independent associates of AC. The risk of AC using either cut points adjusted for pack-years of smoking and additional risk factors was lower in Japanese compared to both white and Japanese-American. AC and CAC had moderately positive and significant correlations in Japanese (r=0.26), white (r=0.39), and Japanese-American (r=0.45).

CONCLUSIONS

The prevalence of AC defined both >0 and ≥ 100 was significantly lower in Japanese than in white and Japanese-American men after adjusting for cigarette smoking and additional risk factors.

Effects of smoking cessation on central blood pressure and arterial stiffness

PURPOSE

Smoking affects arterial stiffness, thus causing an elevation in central blood pressure (CBP). The present study was designed to examine whether smoking cessation treatment improved CBP and arterial stiffness.

PATIENTS AND METHODS

We conducted an observational study of 70 patients receiving smoking cessation treatment. Before and 60 weeks after the start of a 12-week varenicline treatment, we measured brachial blood pressure, CBP, brachial-ankle pulse wave velocity (baPWV), normalized radial augmentation index (rAIx@75), left ventricular weight, and left ventricular diastolic function of each patient. The data were compared between the patients who succeeded in quitting smoking (smoking cessation group; n = 37) and those who failed to quit smoking (smoking group; n = 33).

RESULTS

Baseline characteristics were similar in both groups. Brachial blood pressure remained unchanged in both groups. CBP, baPWV, and rAIx@75 decreased significantly in the smoking cessation group, while these parameters showed no significant change in the smoking group. Thus, CBP, baPWV, and rAIx@75 showed greater decrease in the smoking cessation group than in the smoking group (CBP, -7.1 ± 1.4 mmHg vs 1.2 ± 2.7 mmHg; P < 0.01; baPWV, -204 ± 64 cm/s vs -43 ± 72 cm/s; P < 0.01; rAIx@75, -6.4 ± 2.8% vs -1.0 ± 3.9%; P < 0.01). Left ventricular weight and left ventricular diastolic function remained unchanged in both groups.

CONCLUSION

Patients in the smoking cessation group showed significant improvement in CBP, baPWV, and rAIx@75. These results indicate that smoking cessation can improve arterial stiffness and CBP.

Relation between the incidence, location, and extent of thoracic aortic atherosclerosis detected by transesophageal echocardiography and the extent of coronary artery disease by angiography

Atherosclerotic lesions in the thoracic aorta detected by transesophageal echocardiography (TEE) have been correlated with coronary artery disease (CAD). We determined whether simple or complex aortic plaques seen on transesophageal echocardiogram correlated with extent, location, and severity of CAD. The study population consisted of 188 patients who underwent TEE and coronary angiography. Atherosclerotic plaques seen on transesophageal echocardiogram were defined as (1) complex plaques in the presence of protruding atheroma ≥4-mm thickness, mobile debris, or plaque ulceration or (2) simple plaques in the absence of findings consistent with complex plaques. Extent of CAD was grouped into 4 groups according to number of coronary vessels with ≥70% stenosis. Numbers of patients with CAD with 0-, 1-, 2-, and 3-vessel disease were 99, 31, 28, and 30 respectively. Compared to patients without CAD, patients with CAD (n = 89) had a significantly greater prevalence of aortic atherosclerotic plaques irrespective of degree of plaque complexity or location (p <0.05). Multivariate analysis found that hypertension (odds ratio 3.0, 95% confidence interval 1.3 to 7.0, p = 0.013), diabetes mellitus (odds ratio 2.4, 95% confidence interval 1.1 to 4.9, p = 0.022), and aortic plaque (odds ratio 3.8, 95% confidence interval 1.8 to 8.2, p = 0.001) were significantly associated with CAD. There was a significant relation between simple and complex aortic plaques with increasing severity of CAD (p <0.001). Multivariate logistic regression analysis showed that complex plaque in the descending aorta (odds ratio 5.4, 95% confidence interval 1.8 to 16.4, p = 0.003) was the strongest predictor of CAD. In conclusion, simple and complex thoracic atherosclerotic plaques detected by TEE are associated with increasing severity of CAD. Complex plaque in the descending aorta was the strongest association with presence of CAD.

Polymorphisms in pro- and anti-inflammatory cytokine genes and susceptibility to atherosclerosis: a pathological study of 1503 consecutive autopsy cases

Atherosclerosis is a chronic inflammatory disease in the intima of the arterial wall, where cytokines play a crucial role in the pathogenesis of this disease. However, the question of whether or not genetic variations in the cytokine genes could influence the development of atherosclerosis has been poorly investigated. We investigated the relationship of nine common single-nucleotide polymorphisms (SNPs) in tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1beta, IL-10, IL-4 and transforming growth factor (TGF)-beta1 with the atherosclerotic severity in 10 different arteries based on 1503 consecutive autopsies of elderly Japanese subjects registered in the Japanese SNPs for geriatric research (JG-SNP) study. The -1031C allele of TNF-alpha was a significant protective factor for atherogenesis in the carotid, femoral and intracranial arteries [odds ratio (OR): 0.72, 0.73 and 0.70, respectively]. The -511T of IL-1beta and the +29T of TGF-beta1 were significant risk factors for atherogenesis in the subclavian and intracranial arteries (OR: 1.35 and 1.48, respectively). In contrast, conventional risk factors for atherogenesis, such as hypertension and diabetes mellitus, conferred independent risks for almost all arteries. Functional SNPs in TNF-alpha, IL-1beta and TGF-beta1 genes play a role in atherogenesis, although their influences are less pronounced than those of conventional risk factors and appear to be limited to specific arteries in the Japanese elderly.

Abdominal obesity and carotid artery wall thickness. The Los Angeles Atherosclerosis Study

OBJECTIVE

To determine whether or not abdominal obesity is associated with the intima-media thickness (IMT) of the carotid artery wall independently of total body obesity and major risk factors for atherosclerosis.

DESIGN

: Longitudinal epidemiological study.

SUBJECTS

A total of 573 middle-aged employees of a utility company.

MEASUREMENTS

Sagittal and transverse abdominal diameters, their ratio and difference were used as measures of abdominal obesity.

RESULTS

Abdominal diameters and body mass index (BMI) were significantly associated with blood pressure, serum lipoproteins and fasting insulin. In cross-sectional multiple regression models, the sagittal/transverse ratio and BMI were significantly associated with IMT in the presence of atherosclerosis risk, but the sagittal diameter was not. In longitudinal models, baseline BMI was an independent predictor of IMT progression but the sagittal and transverse diameters were not.

CONCLUSION

These findings do not support the hypothesis that abdominal obesity is an independent predictor of carotid artery IMT. The consistent pattern of association of measures of general obesity with carotid artery IMT emphasizes the continuing need for prevention and control of this important risk factor.

Cardiovascular manifestations of substance abuse: part 2: alcohol, amphetamines, heroin, cannabis, and caffeine

The abuse of alcohol is associated with chronic cardiomyopathy, hypertension, and arrhythmia. Abstinence or using alcohol in moderation can reverse these cardiovascular problems. Alcohol is also distinguished among the substances of abuse by having possible protective effects against coronary artery disease and stroke when used in moderate amounts. Amphetamines (eg, speed, ice, ecstasy) have many of the cardiovascular toxicities seen with cocaine, including acute and chronic cardiovascular diseases. Heroin and other opiates can cause arrhythmias and noncardiac pulmonary edema, and may reduce cardiac output. Cardiovascular problems are less common with cannabis (marijuana) than with opiates, but major cognitive disorders may be seen with its chronic use. It is still controversial whether caffeine can cause hypertension and coronary artery disease, and questions have been raised about its safety in patients with heart failure and arrhythmia.

[Correlation between aortic atherosclerosis at transesophageal echocardiography and coronary atherosclerosis]

The aim of this study was to test the relationship between atherosclerotic plaques in the thoracic aorta detected by transesophageal echocardiography and coronary artery disease detected by angiography. A prospective study was carried out in 103 patients who underwent coronary angiography. All patients underwent transesophageal echocardiography with imaging of the thoracic aorta. Aortic intimal changes were classified in 4 grades. The detection of aortic atheroma plaques was the strongest predictor of coronary artery disease. The presence of aortic plaques on transesophageal study had a sensitivity of 97.6% and a specificity of 80% for angiographically proved obstructive coronary artery disease. The positive predictive value of aortic plaque for obstructive coronary artery disease was 95.3% and the negative predictive value was 88.9%. Compared to the other segments, the detection of atherosclerotic plaque in the descending aorta has the highest sensitivity but the specificity was the highest in the ascending aorta. With older age and in women the specificity decreased, while the sensitivity increased.

A hypothesis out-of-date. the diet-heart idea

An almost endless number of observations and experiments have effectively falsified the hypothesis that dietary cholesterol and fats, and a high cholesterol level play a role in the causation of atherosclerosis and cardiovascular disease. The hypothesis is maintained because allegedly supportive, but insignificant findings, are inflated, and because most contradictory results are misinterpreted, misquoted or ignored.

Origin of atherosclerosis in childhood and adolescence

Atherosclerosis begins in childhood as deposits of cholesterol and its esters, referred to as fatty streaks, in the intima of large muscular arteries. In some persons and at certain arterial sites, more lipid accumulates and is covered by a fibromuscular cap to form a fibrous plaque. Further changes in fibrous plaques render them vulnerable to rupture, an event that precipitates occlusive thrombosis and clinically manifest disease (sudden cardiac death, myocardial infarction, stroke, or peripheral arterial disease). In adults, elevated non-HDL-cholesterol concentrations, low HDL-cholesterol concentrations, hypertension, smoking, diabetes, and obesity are associated with advanced atherosclerotic lesions and increased risk of clinically manifest atherosclerotic disease. Control of these risk factors is the major strategy for preventing atherosclerotic disease. To determine whether these risk factors also are associated with early atherosclerosis in young persons, we examined arteries and tissue from approximately 3000 autopsied persons aged 15-34 y who died of accidental injury, homicide, or suicide. The extent of both fatty streaks and raised lesions (fibrous plaques and other advanced lesions) in the right coronary artery and in the abdominal aorta was associated positively with non-HDL-cholesterol concentration, hypertension, impaired glucose tolerance, and obesity and associated negatively with HDL-cholesterol concentration. Atherosclerosis of the abdominal aorta also was associated positively with smoking. These observations indicate that long-range prevention of atherosclerosis and its sequelae by control of the risk factors for adult coronary artery disease should begin in adolescence and young adulthood.

Lifestyle physical activity interventions. History, short- and long-term effects, and recommendations

INTRODUCTION

Lifestyle physical activity interventions have resulted in response to the public health problem of promoting regular amounts of physical activity to the majority of U.S. adults who remain inadequately or completely inactive. These lifestyle interventions allow a person to individualize his/her physical activity programs to include a wide variety of activities that are at least of moderate intensity and to accumulate bouts of these activities in a manner befitting his/her life circumstances.

METHODS

We reviewed the history of lifestyle physical activity interventions and defined lifestyle physical activity based on this review. We located 14 studies that met this definition.

RESULTS

Lifestyle physical activity interventions are effective at increasing and maintaining levels of physical activity that meet or exceed public health guidelines for physical activity in representative samples of previously sedentary adults and obese children. The majority of these interventions have been delivered by face-to-face contact in small groups, which limits their public health impact. However, a small number of studies demonstrate that these interventions can be delivered by mail and telephone, which may enhance their generalizability. Most of these studies utilized behavior change theories such as Social Cognitive Theory, the Transtheoretical Model, and Behavior Learning to shape the interventions. Lifestyle interventions aimed at modifying the environment, such as signs posted to increase stair climbing, also have been shown to be effective over the short term.

CONCLUSIONS

The major issues concerning lifestyle physical activity interventions are: (1) testing their ability to be implemented on a large scale; (2) examining cost-effectiveness for different modes of delivery; and (3) researching the efficacy in populations such as the elderly, minorities, economically disadvantaged, and individuals with concurrent disease. More studies aimed at manipulating the environment to increase physical activity need to be tested over periods of one year or longer. It is possible that lifestyle interventions could be integrated and delivered by new technologies such as interactive computer-mediated programs, telephone, or computer web-based formats. All of these recommended approaches should utilize valid and reliable measures of physical activity and should examine the health effects, particularly on a longitudinal basis. Basic dose-response studies in controlled settings also are needed to help us understand the health effects of accumulated moderate intensity activity.

The questionable role of saturated and polyunsaturated fatty acids in cardiovascular disease

A fat diet, rich in saturated fatty acids (SFA) and low in polyunsaturated fatty acids (PUFA), is said to be an important cause of atherosclerosis and cardiovascular diseases (CVD). The evidence for this hypothesis was sought by reviewing studies of the direct link between dietary fats and atherosclerotic vascular disease in human beings. The review included ecological, dynamic population, cross-sectional, cohort, and case-control studies, as well as controlled, randomized trials of the effect of fat reduction alone. The positive ecological correlations between national intakes of total fat (TF) and SFA and cardiovascular mortality found in earlier studies were absent or negative in the larger, more recent studies. Secular trends of national fat consumption and mortality from coronary heart disease (CHD) in 18-35 countries (four studies) during different time periods diverged from each other as often as they coincided. In cross-sectional studies of CHD and atherosclerosis, one group of studies (Bantu people vs. Caucasians) were supportive; six groups of studies (West Indians vs. Americans, Japanese, and Japanese migrants vs. Americans, Yemenite Jews vs. Yemenite migrants; Seminole and Pima Indians vs. Americans, Seven Countries) gave partly supportive, partly contradictive results; in seven groups of studies (Navajo Indians vs. Americans; pure vegetarians vs. lacto-ovo-vegetarians and non-vegetarians, Masai people vs. Americans, Asiatic Indians vs. non-Indians, north vs. south Indians, Indian migrants vs. British residents, Geographic Study of Atherosclerosis) the findings were contradictory. Among 21 cohort studies of CHD including 28 cohorts, CHD patients had eaten significantly more SFA in three cohorts and significantly less in one cohort than had CHD-free individuals; in 22 cohorts no significant difference was noted. In three cohorts, CHD patients had eaten significantly more PUFA, in 24 cohorts no significant difference was noted. In three of four cohort studies of atherosclerosis, the vascular changes were unassociated with SFA or PUFA; in one study they were inversely related to TF. No significant differences in fat intake were noted in six case-control studies of CVD patients and CVD-free controls; and neither total or CHD mortality were lowered in a meta-analysis of nine controlled, randomized dietary trials with substantial reductions of dietary fats, in six trials combined with addition of PUFA. The harmful effect of dietary SFA and the protective effect of dietary PUFA on atherosclerosis and CVD are questioned.

Relation of coronary artery disease to atherosclerotic disease in the aorta, carotid, and femoral arteries evaluated by ultrasound

This prospective study was conducted to correlate the presence of angiographically significant coronary artery disease (CAD) and atherosclerotic disease in the aorta, carotid, and femoral arteries as measured by ultrasound. One hundred two consecutive patients admitted for coronary angiography for suspected CAD participated in the study. All patients underwent transesophageal echocardiography for the evaluation of thoracic aortic atherosclerosis and B-mode ultrasound for evaluation of carotid and femoral atherosclerosis. Intimal-medial thickness > 1 mm in the thoracic aorta or peripheral vessels was considered as evidence of atherosclerosis. Patients with CAD (n = 64) had a significantly higher incidence of atherosclerotic plaques in the thoracic aorta, carotid, and femoral arteries than subjects with normal coronary arteries: 91%, 72%, 77% vs 31%, 47% and 42%, respectively. Extracoronary plaque was a stronger predictor of CAD than conventional risk factors. Evidence of plaque in patients younger than median age (64 years) had a higher specificity than in patients above median age (77% vs 40%, respectively, p <0.0001). Plaque score of the extracardiac vessels was significantly higher in patients with multivessel CAD than in patients with 1-vessel CAD disease and in subjects with normal coronary arteries (p <0.001). Thus, atherosclerotic plaques in the aortic and femoral arteries and, to a lesser extent, in the carotid arteries are strong predictors of CAD.

The inverse relation of average population blood pressure and stroke mortality rates in the seven countries study: a paradox

This study attempts to explain the unexpected finding of an inverse population (ecological) relationship between mean systolic blood pressure levels and stroke death rates in 25 years follow-up of the Seven Countries Study, a cross-cultural study of cardiovascular disease. Sixteen cohorts of all men aged 40-59 in seven countries (one cohort in the USA, two in Finland, one in the Netherlands, three in Italy, two in Croatia (former Yugoslavia), three in Serbia (former Yugoslavia), two in Greece, two in Japan) were surveyed from 1958 to 1964. Risk factors and personal characteristics were measured and follow-up for vital status and cause of death was then carried out over 25 years. Analyses were based on comparisons of mean levels of risk factors and death rates within and among the 16 cohorts. Mean entry population levels of systolic blood pressure among the cohorts were strongly and inversely related with their 25-year stroke death rates (R -0.55; CI -0.81 and -0.06; p = 0.0276). Within cohorts in contrast, the individual relation of blood pressure and stroke was strongly positive and significant in 14 of the 16 cohorts. Mean population levels of serum cholesterol were inversely and strongly related to stroke death rates (R -0.79; CI -0.92 and -0.46; p = 0.0003), while the partial correlation coefficient of systolic blood pressure, computed in models including serum cholesterol, became small and not significant (-0.05; CI -0.55 and +0.48; p = 0.8537). Age at death for stroke (average 68.9 +/- 7.1 years) was significantly higher than age at dath from myocardial infarction and sudden death (average 65.8 +/- 7.8 years) suggesting a competition effect between the conditions. Multivariate models including population average systolic blood pressure and serum cholesterol provided no added explanation for the lack of direct and significant relationship of population blood pressure with stroke death rates. They were based on these variables: age at stroke death, age at myocardial infarction death or and sudden death, death rates from myocardial infarction and sudden death, the interaction term of systolic blood pressure with serum cholesterol and the multivariate coefficients for systolic blood pressure from Cox models run in individuals. Similar findings were obtained using diastolic instead of systolic blood pressure and excluding the Japanese cohorts. The paradox of the inverse ecologic relation of population blood pressure and stroke mortality and a direct relation for individual is only partly explained by the cofounding effect of population mean serum cholesterol levels. An effect of low cholesterol levels on excess stroke mortality cannot be excluded. A major limitation of the study was our inability to segregate thrombotic from heamorrhagic strokes.

Cardiovascular risk factors and hyalinization of renal arterioles at autopsy. The Honolulu Heart Program

Nephrosclerosis, commonly found in subjects with hypertension and diabetes, is marked by hyalinization of arterioles and fibroplasia of small arteries in the renal cortex. Cardiovascular risk factors that predicted subsequent hyalinization of renal arterioles at autopsy were identified, using data from the Honolulu Heart Program, a prospective epidemiological study of cardiovascular disease (CVD) in Japanese-American men. Among 8006 participants at baseline, 1381 died between 1965 and 1982; 285 of these had a protocol autopsy, and 150 had assessments of arteriolar hyalinization from renal tissue. Subjects were categorized into four groups on the basis of the number of hyalinized arterioles per square centimeter of renal tissue, and CVD risk factor levels and proportions were compared across these groups with the use of general linear models and logistic regression. Multivariate assessment using logistic regression demonstrated that diastolic blood pressure (DBP) and glucose level were positively associated and alcohol intake was negatively associated with an elevated degree of renal arteriolar hyalinization, independent of other CVD risk factors. The odds ratios for elevated hyalinization associated with a 10-mm Hg increase in DBP, a 20-mg/dL increase in glucose level, and a 30-mL/d increase in alcohol intake were 1.97 (95% confidence interval [CI] = 1.24-3.12), 1.23 (95% CI = 1.07-1.41), and 0.24 (95% CI = 0.11-0.55), respectively. Associations were similar when prevalent cases of CVD were excluded and when autopsy selection bias was taken into account. Renal arteriolar hyalinization was also more strongly associated with atherosclerosis in the larger cerebral vessels (Spearman's r = .59, P < .001) than in the coronary arteries (r = .16, P = .073) and aorta (r = .24, P = .022). Hyalinization was significantly related to cardiovascular-renal mortality, and this association was accounted for by other CVD risk factors. These findings suggest that blood pressure, glucose level, and alcohol intake are independent predictors of hyalinization in renal arterioles and that this type of renal vasculopathy may be a marker for atherosclerosis in other vascular regions, particularly the cerebral vessels. The protective association involving alcohol and the possibility that renal arteriolar hyalinization may be an indicator of cerebral atherosclerosis may warrant investigation in other populations.

Frequency and distribution of atherosclerotic plaques in the thoracic aorta as determined by transesophageal echocardiography in patients with coronary artery disease

The frequency, distribution, and severity of thoracic aortic plaques were evaluated by transesophageal echocardiography in 152 consecutive patients undergoing coronary arteriography. Coronary artery disease (CAD) was defined as > or = 50% stenosis of > or = 1 major branch. Atherosclerotic plaques were detected in the aorta in 90 of the 97 patients (93%) with CAD, but in only 12 of the 55 patients (22%) with normal coronary arteries. Atherosclerotic plaques in patients with CAD were found predominantly in the descending aorta (in 93%) and in the aortic arch (in 80%), whereas the ascending aorta was the least involved (in 37%). In the descending aorta, 58% of the plaques were complex (>3 mm thick, ulcerated, mobile, or calcified), and in the aortic arch, 40% of the plaques were so classified. Complex plaques were not found in the ascending aorta. The presence of an atherosclerotic plaque in the descending aorta had a sensitivity and a specificity for the prediction of CAD of 93% and 78%, respectively. In the ascending aorta, the sensitivity was lower (37%) but the specificity was higher (100%). The sensitivity of aortic plaques for the prediction of CAD was high in all age groups. Its specificity in subjects >63 years was lower than in younger subjects: 64% versus 90%, respectively. Multivariate logistic regression analysis showed that aortic plaques were a stronger predictor of CAD than were conventional risk factors.

Predictors of myocardial lesions in men with minimal coronary atherosclerosis at autopsy. The Honolulu heart program

Some cardiovascular risk factors are associated with clinical coronary heart disease but not with autopsy evidence of coronary atherosclerosis. To determine whether these risk factors might operate through mechanisms other than atherosclerosis, we examined associations between cardiovascular risk factors and subsequent intramural myocardial lesions assessed by protocol autopsy between 1965 and 1984 in 120 Japanese-American men from the Honolulu Heart Program who had minimal coronary atherosclerosis (American Heart Association (AHA) panel score < 3 on scale of 1 to 7). Age-adjusted prevalence of myocardial lesions was related to smoking status (P < 0.01), as well as amount, duration, and pack-years of smoking (P < 0.03). In a multiple logistic model, smoking (20 pack-years) was directly associated and fish intake (> or = 2 times/wk) was inversely associated with myocardial lesions independently of age, cholesterol, systolic blood pressure, body mass index, alcohol, diabetes, total calories, and animal protein intake (odds ratio (OR) = 1.5, 95% confidence intervals (CI) = 1.1 to 2.0 and OR = 0.35, 95% CI = 0.2 to 0.9, respectively). The protective effect of fish intake was most evident among men who did not have hypertension at baseline. Indices of obesity, body fat distribution, and physical activity and levels of triglyceride and alcohol intake were not associated with myocardial lesions. Thus, the adverse effects of smoking and the protective effects of fish consumption may extend to individuals relatively free of coronary atherosclerosis, possibly through hemostatic mechanisms or effects on small intramural arteries.

Low serum cholesterol and mortality. Which is the cause and which is the effect?

BACKGROUND

Many studies have reported an association between a low or lowered blood total cholesterol (TC) level and subsequent nonatherosclerotic disease incidence or death. The question of whether low TC is a true risk factor or alternatively a consequence of occult disease at the time of TC measurement remains unsettled. To shed new light onto this problem, we analyzed TC change over a 6- year period (from exam 1 in 1965 through 1968 to exam 3 in 1971 through 1974) in relation to subsequent 16-year mortality in a cohort of Japanese American men.

METHODS AND RESULTS

The study was based on 5941 men 45 to 68 years of age without prior history of coronary heart disease, stroke, cancer, or gastrointestinal-liver disease at exam 1 who also participated in exam 3 of the Honolulu Heart Program. The association of TC change with mortality end points was investigated with two different approaches (continuous and categorical TC change) with standard survival analysis techniques. Falling TC level was accompanied by a subsequent increased risk of death caused by some cancers (hemopoietic, esophageal, and prostate), noncardiovascular noncancer causes (particularly liver disease), and all causes. The risk-factor-adjusted rate of all-cause mortality was 30% higher (relative risk, 1.30; 95% CI, 1.06 to 1.59) among persons with a decline from middle (180 to 239 mg/dL) to low (< 180 mg/dL) TC than in persons remaining at a stable middle level. By contrast, there was no significant increase in all-cause mortality risk among cohort men with stable low TC levels. Nonillness mortality (deaths caused by trauma and suicide) was not related to either TC change or the average of TC levels in exams 1 and 3.

CONCLUSIONS

These results add strength to the reverse-causality proposition that catabolic diseases cause TC to decrease.

Atherosclerosis in alcoholics

A cohort of alcoholics who underwent a medico-legal autopsy during a 5-year period was compared with non-alcoholic controls who did not differ from the alcoholics in selection criteria. The degree of atherosclerosis in the coronary arteries and the aorta was examined. Alcoholic men and old women had a significantly lower degree of atherosclerosis in the coronary arteries, while the opposite was found in young women. In the aorta there was no significant difference in the degree of atherosclerosis between alcoholics and controls in men. Alcoholic women generally had a lower degree of atherosclerosis in the aorta. The so-called U-shaped curve for the relationship between the daily alcohol intake and atherosclerosis is described together with some of the investigations on which it is based. There is much positive evidence for the U-shaped curve, although a causal association has not been proven as yet. The present results indicate a complex relationship, in which different confounding factors are likely to play a role.

Postprandial lipoprotein responses in hypertriglyceridemic subjects with and without cardiovascular disease

Three groups of age- and weight-matched men (aged 40 to 70 years) without diabetes were studied: controls (n = 10), plasma triglycerides (TG) less than 180 mg/dL and no cardiovascular disease (CVD); HTG-CVD (n = 11), hypertriglyceridemic (HTG) (TG > 240 mg/dL) without CVD; and HTG+CVD (n = 10), HTG (TG > 240 mg/dL) with documented CVD. HTG+CVD subjects had higher fasting and post-oral glucose tolerance test insulin levels than the other two groups, respectively. Very-low-density lipoprotein (VLDL)+chylomicrons (CMs), intermediate-density lipoprotein (IDL), low-density lipoprotein (LDL), and three high-density lipoprotein (HDL) subfractions (HDL-L, HDL-M, and HDL-D, from least to most dense) were isolated by gradient ultracentrifugation. Fasting lipoproteins were similar in HTG groups, except for higher VLDL lipid to apolipoprotein (apo) B ratios (P < .04) in the HTG+CVD group. Subjects were fed a high-fat mixed meal, and lipoprotein composition was determined at 3, 6, 9, and 12 hours postprandially. Postprandial responses of the core lipids (TG and cholesterol esters [CE]) in all of the lipoprotein subfractions were similar in the two HTG groups at each time point. However, both controls and HTG-CVD subjects had increases in HDL-M phospholipid (PL) at 9 and 12 hours with no change in HDL-D PL. The HTG+CVD group, on the other hand, had no increase in HDL-M PL and had a substantial reduction in HDL-D PL. These changes resulted in significant increases in HDL-M and HDL-D PL to apo A-I ratios in both controls and HTG-CVD subjects between 6 and 12 hours, whereas there was no increase seen in the HTG+CVD group. The HTG-CVD group also had a significantly greater increase in the VLDL+CM PL to apo B ratio (P = .038) at 3 hours than the HTG+CVD group. This diminished amount of surface lipid per VLDL particle may account for the late decrease in the HDL-D PL to apo A-I ratio seen in HTG+CVD patients. There were no other postprandial lipid or apolipoprotein differences between the two HTG groups. We conclude therefore that the major postprandial lipoprotein abnormality in these HTG+CVD patients was a failure to increase the PL content per particle in VLDL+CM, HDL-M, and HDL-D. This abnormality could prevent the usual increase in reverse cholesterol transport seen in postprandial plasma and therefore contribute to their increased incidence of CVD. The greater insulin resistance seen in these patients also appears to contribute significantly to their CVD.

Coffee: brew or bane?

Coffee is the most commonly used drug in the United States. The medical literature is conflicted regarding the harmful effects of coffee and caffeine. Because the articles that have appeared are so different, a formal meta-analysis is not the ideal way to summarize the data. However, this literature review suggests that coffee does not have an appreciable effect on hyperlipidemia, hypertension, ischemic heart disease, or cancer. The effects of decaffeinated coffee are much less well-defined, and there is little rationale for recommending that patients switch to decaffeinated coffee. A less appreciated problem with caffeine is that it may increase the risk of osteoporosis and hip fracture.

Cigarette smoking and the development and progression of aortic atherosclerosis. A 9-year population-based follow-up study in women

BACKGROUND

Cigarette smoking has been recognized as an important risk factor for cardiovascular disease in men and women. Whether the increased risk results from an atherogenic effect of smoking is still debated. We examined the relation between cigarette smoking and atherosclerotic changes in the abdominal aorta.

METHODS AND RESULTS

The association between cigarette smoking and atherosclerotic changes in the abdominal aorta was examined in a population-based cohort of 758 women, initially aged 45 to 64 years. All women were examined radiographically for calcified deposits in the abdominal aorta, which have been shown to represent intimal atherosclerosis. After 9 years of follow-up, atherosclerotic changes, indicating development or progression of plaques, could be demonstrated in 37% of women. A direct association was found between atherosclerotic change and number of cigarettes smoked per day. Compared with women who had never smoked, the relative risks of those who smoked 1 to 9, 10 to 19, and 20 or more cigarettes per day were 1.4 (95% confidence interval, 1.0 to 2.0), 2.0 (1.6 to 2.5), and 2.3 (1.8 to 3.0), respectively, after adjustment for age and other cardiovascular risk factors. Associations of atherosclerotic change with inhaling habit and duration of smoking were borderline significant after number of cigarettes smoked per day was taken into account. Among former smokers, the risk decreased with increasing duration of stopping but a significant excess risk was still observed after 5 to 10 years since quitting (relative risk, 1.6; 95% confidence interval, 1.1 to 2.2).

CONCLUSIONS

These follow-up data support the evidence for an effect of cigarette smoking on atherosclerosis. The findings suggest that the rate of atherosclerotic change may be reduced by cessation of smoking, but a residual effect appears to be present for at least 10 years.

The atherogenic potential of carbon monoxide

This paper reviews the available evidence concerning the atherogenic potential of carbon monoxide. The evidence comes from two different types of studies--epidemiology studies on populations of humans chronically exposed to carbon monoxide, and animal studies conducted under conditions of controlled exposure to carbon monoxide. Data from both epidemiology and animal studies suggest that carbon monoxide is not atherogenic. Therefore, the increased levels of atherosclerosis associated with smoking as reported in epidemiology studies of human smokers probably cannot be attributed to CO exposure.

Dehydroepiandrosterone sulfate, incidence of myocardial infarction, and extent of atherosclerosis in men

BACKGROUND

Antiatherogenic effects of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS) have been suspected for more than 30 years, yet the available evidence to support or refute such effects in humans is inconclusive. The hypothesis has not been adequately tested in large-scale epidemiological studies.

METHODS AND RESULTS

The present study used a cohort of men initially free of clinically detectable coronary heart disease, stroke, and cancer to compare DHEAS levels measured in sera obtained in 1968-1971 between 238 cases who had definite coronary heart disease during the subsequent 18 years and 476 age-matched controls who survived the follow-up period and remained free of clinically detectable coronary heart disease. In a separate study, the relation of DHEAS levels to extent of atherosclerosis was examined among 82 cohort men who died during the follow-up period and had protocol autopsies. Age-adjusted DHEAS levels were lower among fatal cases of coronary heart disease than among controls (94.7 versus 106.9 micrograms/dl, respectively; p < 0.05). After adjustment for eight coronary risk factors, the odds ratio for fatal coronary heart disease comparing a 100-micrograms/dl difference in DHEAS level was 0.46 (95% confidence intervals, 0.19-1.07). In contrast, age-adjusted DHEAS levels did not significantly differ between nonfatal cases of myocardial infarction and controls (107.2 versus 106.9 micrograms/dl, respectively). Furthermore, DHEAS levels were not related to extent of atherosclerosis at autopsy.

CONCLUSIONS

These findings do not support a role of DHEAS in the development of nonfatal myocardial infarction or the progression of atherosclerosis. The association of DHEAS with fatal coronary heart disease and possibly with death from all causes merits further investigation. These findings suggest continued skepticism that DHEAS has an important role in coronary disease etiology or prevention.

Do coronary heart disease risk factors measured in the elderly have the same predictive roles as in the middle aged. Comparisons of relative and attributable risks

Risk factors for the 12-year incidence of definite coronary heart disease (CHD) among 3440 men who were middle-aged (51 to 59 years old) and 1419 men who were elderly (65 to 74 years old) at baseline examination were examined for differences in predictive values in terms of both relative risk and attributable (excess) risk of the highest versus the lowest quartile or appropriate categories. In multivariate models using Cox life-table regression procedures, serum cholesterol level, cigarette smoking, systolic blood pressure, and history of treatment for diabetes were significant predictors of incident CHD for both age groups. Alcohol consumption when modeled as drinker versus nondrinker showed a protective effect in both younger and older men. There was no dose relationship, however, among elderly drinkers. While the relative risks for the variables studied were similar between the two age groups, the excess risk was typically between 1.5 to 2.0 times higher for the older than the middle-aged men. In contrast, the detrimental effect of adiposity as measured by body mass index appeared to decline after age 65 for both measures of risk. This may partly be attributed to diminished adiposity overall in the older age group. The implications of these results are that serum cholesterol level, smoking, hypertension, diabetes, and possibly alcohol consumption continue to be important predictors for CHD when measured after age 65, and that the public health impact of these risk factors, in terms of excess risk, may be more important in the elderly.

Does a reduced fat diet cause retardation in child growth?

BACKGROUND

A diet low in saturated fat and cholesterol is strongly recommended by the American Heart Association and the National Cholesterol Education Program as a way to prevent coronary heart disease. In addition, the National Cancer Institute has suggested that dietary fat restriction may also prevent the development of some cancers. However, the American Academy of Pediatrics reviewed the same evidence in relation to children and concluded that that major dietary changes recommended for adults should not be prescribed for children.

METHODS

In this article, we review the evidence for the detrimental consequences associated with dietary fat restriction for children. Evidence from studies on secular trends, migration, and vegetarian communities suggests minor effects of dietary fat restriction upon growth. In addition, there is some evidence indicating that children who are placed on severe dietary restriction during growth periods may experience growth stunting. Virtually all of the published studies have serious methodological limitations.

CONCLUSION

We conclude that dietary fat restriction may have some small, but measurable, effects upon growth.

Are aortic aneurysms caused by atherosclerosis?

BACKGROUND

The emerging controversy concerning the causal role of atherosclerosis in the development of aortic aneurysms was examined using the accumulated clinical and autopsy data obtained during a 20-year follow-up of a cohort of more than 8,000 men of Japanese ancestry in Hawaii.

METHODS AND RESULTS

Analyses of 174 clinical incident events indicated that there were two types of aneurysmal disease, 151 aortic aneurysms and 23 aortic dissections. The baseline risk factors that predicted the clinical aortic aneurysms were the same factors that predicted aortic atherosclerosis in the same cohort, namely, high blood pressure, high serum cholesterol, and cigarette smoking. These same risk factors were also significantly associated with the occurrence of 27 aortic aneurysms among 293 autopsied men. The less common aortic dissections had an age-specific incidence pattern indicative of an innate susceptibility precipitated by an exposure to another factor. This pattern was consistent with the findings that the incidence of aortic dissections was predicted mainly by baseline high blood pressure.

CONCLUSIONS

From the perspective of prevention, it appears that the risk factors for aortic atherosclerosis and probably atherosclerosis itself are necessary elements in the causal pathway for the great majority of aortic aneurysms in this cohort.

Lack of effect of lovastatin therapy on the parameters of whole-body cholesterol metabolism

The effects of lovastatin therapy on the parameters of body cholesterol metabolism were explored in nine hypercholesterolemic patients. Long-term cholesterol turnover studies were performed before therapy, and were repeated after 15 mo of lovastatin therapy (40 mg/d) while continuing on therapy. The major question addressed was whether a reduction in plasma cholesterol level with lovastatin would be associated with a reduction in the whole-body production rate of cholesterol or with the sizes of exchangeable body cholesterol pools as determined by the three-pool model of cholesterol turnover. The mean plasma cholesterol level decreased 19.4% (from 294 to 237 mg/dl), and low-density lipoprotein cholesterol decreased 23.8% (from 210 to 159 mg/dl) with lovastatin therapy. Changes in high-density lipoprotein cholesterol level were not significant. The cholesterol production rate did not change significantly with therapy (1.09 +/- 0.10 [mean +/- S.D.] vs. 1.17 +/- 0.09 g/d). By comparison, colestipol and niacin treatment in three other subjects more than doubled the cholesterol production rate (1.14 +/- 0.28 vs. 2.42 +/- 0.34 g/d). Thus, hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibition by lovastatin at the therapeutic dose used here did not change the steady-state rate of whole-body cholesterol synthesis. Despite the changes in plasma cholesterol levels, no significant changes were seen in the values of M1, of M3 or of Mtot, the sizes of the pools of rapidly, of slowly, and of total body exchangeable cholesterol.

CONCLUSION

lovastatin therapy to lower plasma cholesterol does not lead to corresponding reductions in body cholesterol pools or to a reduction in the rate of whole-body cholesterol synthesis. In the new steady state that exists during long-term lovastatin therapy, along with increased expression of the genes for HMG-CoA reductase and the LDL receptor, the body compensates for the effects of the drug so that cholesterol production rate and tissue pool sizes are not changed from pretreatment values.

Serum lipids and lipoproteins as predictors of atherosclerosis. An autopsy study

A prospective study of autopsy-determined measures of atherosclerosis in aortas and coronary and cerebral arteries was completed for a group of 83 men who were free of clinical cardiovascular disease and cancer when they entered the Cooperative Lipoprotein Phenotyping Study in 1970. Total cholesterol minus high density lipoprotein cholesterol (HDL-C) was significantly associated with measures of atherosclerosis in all three groups of vessels. The patterns of associations for total, low density lipoprotein, and very low density lipoprotein cholesterol were similar but generally weaker and not significant for atherosclerosis in the cerebral arteries. Inverse associations of HDL-C with atherosclerosis in the circle of Willis and aorta were significant, but those for the coronary arteries were not. These associations were independent of other major risk factors for atherosclerosis in multivariate analyses. Similarities between these findings and those for clinical cardiovascular disease in the same cohort indicate that the opposing patterns of increased risk of clinical cardiovascular disease associated with total cholesterol and the decreased risk associated with HDL-C also exists at the level of atherosclerosis in a variety of arteries.

Comparison of two measures of atherosclerosis in a prospective epidemiology study

Two different methods of measuring atherosclerosis, the American Heart Association panel method and the International Atherosclerosis Project unaided visual estimation, were used to estimate the extent of atherosclerosis in the coronary arteries and aortas from 225 men who participated in a prospective study of cardiovascular disease. The two methods produced quite different results of frequency distribution of levels of atherosclerosis. The correlations of the two measures of atherosclerosis were also relatively low for both the coronary arteries (0.63) and the aortas (0.74). The correlation of atherosclerosis with major risk factors was generally higher with the unaided visual estimation method than with the panel method, except for cigarette smoking. However, the associations of coronary atherosclerosis with autopsy-documented myocardial infarction and with clinical coronary disease were similar for the two measures. Thus, it is clear that the estimate of extent of atherosclerosis and its associations with major risk factors depends upon the method used to measure atherosclerosis. Epidemiologic studies that use only one method may miss some types of risk factor associations.

Dietary factors related to physical fitness among navy shipboard men

Abstract This study examines the relationship between habitual dietary practices and performance on the physical readiness test required of active duty Navy personnel. Participants were 1,013 men (mean age = 26.2 years) stationed aboard nine Navy ships. The men completed a self-report survey of lifestyle and dietary habits and were evaluated on four tests of physical fitness: 1.5-mile Run, Sit-ups, Sit-reach, and Percent Body Fat. A standardized Overall Fitness score was also computed for each person. Results indicated that the participants tended to skip breakfast, ingest moderate amounts of caffeine, and favor a high-fat, low-fiber diet. Fitness scores were associated with a number of dietary variables, including caffeine intake, between-meal snacking, and overeating (all negatively related to fitness, p <.01), and having a general "nutrition orientation" (positively related to fitness, p <.001). The relationships were confounded by the influence of age, exercise, and smoking, but even after controlling for these, diet was a significant predictor of fitness (p <.001).

A prospective study of cerebral artery atherosclerosis

Atherosclerosis in the circle of Willis and its major branches was studied prospectively in 198 men in the Honolulu Heart Program who were free of cardiovascular disease at the entry examination. The level of atherosclerosis was greater in the large arteries of the circle of Willis than in the small arteries, and autopsy-verified cerebral infarction was strongly associated with increasing severity of atherosclerosis in both. Analyses of the association of atherosclerosis scores with biologic and lifestyle characteristics measured at entry into the study indicated that atherosclerosis in the large arteries was consistently related to age, diastolic blood pressure, serum cholesterol, and height (inversely). Weak trends of association were also found with increasing serum glucose concentration, increasing cigarette use, and decreasing alcohol intake. Atherosclerosis scores in the small arteries were associated with diastolic blood pressure and serum triglyceride concentration. Analysis of dietary intake indicated that atherosclerosis scores were higher for men who reported low intakes of fat and animal protein and high intakes of vegetable protein and total carbohydrates. These patterns were consistent with similar findings on the incidence of clinical stroke in this cohort. Age-adjusted and -specific atherosclerosis scores from both the large and small arteries declined significantly during the period 1965-1983.