Prospective Association Between Low and High Total and Low-Density Lipoprotein Cholesterol and Coronary Heart Disease in Elderly Men

Cardiovascular Risk Factor Control in 70- to 95-Year-Old Individuals: Cross-Sectional Results from the Population-Based AugUR Study

Cardiovascular risk factors such as high glucose, LDL-cholesterol, blood pressure, and impaired kidney function are particularly frequent in old-aged individuals. However, population-based data on the extent of cardiovascular risk factor control in the old-aged population is limited. AugUR is a cohort of the mobile “70+”-year-old population of/near Regensburg, recruited via population registries. We conducted cross-sectional analyses assessing the proportion of AugUR participants with LDL-cholesterol, HbA1c, or blood pressure beyond recommended levels and their association with impaired creatinine- and cystatin-based estimated glomerular filtration rate (eGFR, <60 mL/min/1.73 m2) or urine albumin–creatinine ratio (UACR, ≥30 mg/g). Among 2215 AugUR participants, 74.7% were taking lipid-, glucose-, blood-pressure-lowering, or diuretic medication. High LDL-cholesterol at ≥116 mg/dL was observed for 76.1% (51.1% among those with prior cardiovascular events). We found HbA1c ≥ 7.0% for 6.3%, and high or low systolic blood pressure for 6.8% or 26.5%, respectively (≥160, <120 mmHg). Logistic regression revealed (i) high HbA1c levels associated with increased risk for impaired kidney function among those untreated, (ii) high blood pressure with increased UACR, and (iii) low blood pressure with impaired eGFR, which was confined to individuals taking diuretics. Our results provide important insights into cardiovascular risk factor control in individuals aged 70–95 years, which are understudied in most population-based studies.

Statins in Primary Prevention in People Over 80 Years

In the much older population (≥80 years), the management of cardiovascular diseases requires specific research to avoid a plain transposition of medical practice from younger populations. Whether statins are useful in primary prevention in this population is not clear. The 3 intricate issues requiring attention are (1) the impact of hypercholesterolemia on mortality and major adverse cardiovascular events in subjects >80 years, (2) the efficacy of statins to prevent cardiovascular events at this age, and (3) the safety and tolerance of statins in this population. Three systematic reviews were performed using a search on EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases including publication until January 2021. Among the 7,617 references identified, 29 were finally retained. Regarding the first objective (16 studies, 121,250 participants), 7 studies (10,241 participants) did not find total cholesterol and low-density lipoprotein levels associated with an increased rate of major cardiovascular events in octogenarians. A total of 6 studies (14,493 participants) found increased levels associated with events, whereas 3 studies (96,516 participants) found the opposite, with increased risk of major adverse cardiovascular events with lower levels of cholesterol. In 8 studies (436,005 participants) addressing the efficacy of statins, most did not indicate a significant decrease in the rate of major cardiovascular events in these subjects. Finally, regarding tolerance (9 studies, 217,088 participants), the most important side effects in this population were muscular, hepatic, and gastrointestinal disorders. These events were more frequent than in the younger population. In conclusion, in the absence of convincing evidence, the benefit of statins in primary prevention for much older patients is not certain. Their prescription in this setting should only be considered case by case, taking into consideration physiological status, co-morbidities, level of risk, and expected life expectancy. Specific trials are mandatory.

Association of low-density lipoprotein cholesterol levels with the risk of mortality and cardiovascular events: A meta-analysis of cohort studies with 1,232,694 participants

BACKGROUND

Lowering elevated low-density lipoprotein cholesterol (LDL-C) is an important strategy to prevent cardiovascular disease (CVD), while some studies report low LDL-C increases all-cause mortality. Our study aimed to explore the appropriate low LDL-C level with the lower CVD risk but with no excess risk for all-cause mortality.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were searched until April 7, 2021. Twenty cohort studies with 1232,694 adults were obtained. Effect size index was evaluated using pooled relative risk (RR) with 95% confidence interval (CI). Heterogeneity was assessed using the Cochran's Q test and I2 statistic, and heterogeneity sources was investigated using meta-regression. Publication bias was assessed and sensitivity analysis was performed.

RESULTS

The risks of all-cause mortality (RR: 1.34, 95%CI: 1.00-1.80), CVD death (RR: 1.79, 95%CI: 1.26-2.54), CHD death (RR: 2.03, 95%CI: 1.36-3.03) were higher in LDL-C ≥ 160 mg/dL than LDL-C of 70-129 mg/dL. Both LDL-C of 130-159 mg/dL and ≥ 160 mg/dL were associated with higher CVD risk than LDL-C of 70-129 mg/dL, with RR of 1.26 (95%CI: 1.08-1.47) and 1.70 (95%CI: 1.35-2.14), respectively. Compared to LDL-C of 70-129 mg/dL, no association was found between LDL < 70 mg/dL and all-cause mortality and CVD events.

CONCLUSION

Our results found LDL-C ≥ 130 mg/dL was associated with the higher risk of all-cause mortality and CVD risk, indicating that adults with high LDL-C should take interventions to regulate the LDL-C level lower than 130 mg/dL.

The Associations of Lipid Profiles With Cardiovascular Diseases and Death in a 10-Year Prospective Cohort Study

Background: Dyslipidemia is one of the modifiable risk factors for cardiovascular diseases (CVD). Identifying subjects with lipid abnormality facilitates preventative interventions.

Objectives: To evaluate the effects of lipid indices on the risks of ischemic stroke (IS), coronary heart disease (CHD), CVD, all-cause death, and CVD death.

Methods: The cohort study of 4,128 subjects started in May 2009 and followed up to July 2020. Restricted cubic spline (RCS) regression analysis was used to explore the dose-response relationship between lipid indices with outcomes. Cox proportional hazard regression analysis was used to estimate the association with a hazard ratio (HR) and 95% CI.

Results: RCS analysis showed that there were significant linear associations of TG with IS, non-high-density lipoprotein cholesterol (HDL-C), apolipoprotein B (ApoB), and total cholesterol (TC)/HDL-C ratio with all-cause death, non-HDL-C and RC with CVD death, and significant non-linear associations of ApoB with IS and CVD, TC, LDL-C, ApoAI, and TC/HDL-C ratio with CHD, and TC with all-cause death (all P <0.1). Cox regression analysis revealed that subjects with TC <155 mg/dl (vs. 155–184 mg/dl), > 185 mg/dl (vs. 155–184 mg/dl), and ApoB <0.7 g/l (vs. ≥0.7 g/l) had higher risks of CHD (P < 0.05), the adjusted HRs (95% CIs) were 1.933 (1.248–2.993), 1.561 (1.077–2.261), and 1.502 (1.01–2.234), respectively. Subjects with ApoAI > 2.1 g/l (vs. 1.6–2.1 g/l) and TG <80 mg/dl (vs. 80–177 mg/dl) had higher risks of CVD and all-cause death (P < 0.05), the adjusted HRs (95% CIs) were 1.476 (1.031–2.115) and 1.234 (1.002–1.519), respectively.

Conclusions: Lower or higher levels of TC, higher level of ApoAI, and lower level of ApoB were associated with increased risks of CVD, and lower level of TG was associated with increased all-cause death. Maintaining optimal lipid levels would help to prevent CVD and reduce mortality.

Dyslipidemia and prevention of atherosclerotic cardiovascular disease in the elderly

The atherosclerotic cardiovascular disease (ASCVD) represents the leading cause of death and disability in the elderly. The study of atherosclerosis and the strategies to control ASCVD are evolving. All strategies emphasize the need to lower LDL cholesterol (LDL-C) through an appropriate lifestyle and the use of lipid-lowering drugs, mainly statins. Available evidence coming from clinical trials is useful to inform clinical choices but the older people are poorly represented in those trials. Thus evidence supporting the benefit of statin therapy for primary and secondary prevention of fatal and nonfatal ASCVD events in adults aged 75 years and older are limited. The pharmacological therapy of dyslipidemia is recommended by guidelines provided by international expert panels in adults, while in the elderly it is still a matter of debate. Statins are generally well tolerated drugs but their use in the elderly, especially in fragile ones or with multi-pathology that take many other drugs, requires a careful evaluation of the risk-benefit ratio and a shared decision-making process between doctor and patient.

Paradoxical association between atrial fibrillation/flutter and high cholesterol over age 75 years: The Kuakini Honolulu Heart Program and Honolulu-Asia Aging Study

INTRODUCTION

Several studies have indicated high cholesterol is paradoxically associated with low prevalence of atrial fibrillation/flutter (AF). However, the etiology is uncertain. One potential explanation might be the confounding effect of age exemplifying prevalence-incidence (Neyman's) bias. However, this bias has not often been discussed in depth in the literature. Therefore, we conducted a cross-sectional analysis to test the hypothesis that there is a paradoxical association between lipid profile and AF prevalence.

METHODS

This is a cross-sectional study design, using data from the Kuakini Honolulu Heart Program. Participants were 3741 Japanese-American men between 71 and 93 years old living in Hawaii. Serum total cholesterol (TC) level was measured and categorized into quartiles. AF was diagnosed by 12‑lead Electrocardiogram. We categorized age into quartiles (71-74, 75-77, 78-80 and 81+ years).

RESULTS

We observed opposite associations between AF and TC among different age groups. For participants age ≥75, higher TC levels were paradoxically associated with lower prevalence of AF after multivariable adjustment, i.e. the odds ratios of AF comparing the highest TC quartile with the lowest TC quartile for age 75-77, 78-80 and 81+ years were 0.17 (95% confidence interval [CI], 0.06-0.52), 0.28 (95% CI, 0.07-1.09) and 0.14 (95% CI, 0.03-0.62), respectively. Conversely, for those who were 71-74 years old, the odds ratio of AF was 2.09 (95% CI, 0.76-5.75) between the highest and the lowest TC quartiles.

CONCLUSIONS

There is a paradoxical association of TC with AF in Japanese-American men age ≥75, but not <75 years. The paradox might be explained by Neyman's bias.

Controlling the thickness of the atherosclerotic plaque by statin medication

Atherosclerosis, a chronic inflammatory disorder of the arterial wall, is a complex process whose dynamics are affected by multiple factors. The disease control consists of restraining it by administering statins. Slowing down or halting the plaque growth depends on the patient age at which the statin treatment begins and on the thickness of the intima-media (IMT) at that time. In this paper, we propose a mathematical model to estimate the sets of atherosclerosis states, from which the use of statins can restrain the disease. Our model is control-theoretic, and the estimated sets are the viability kernels, in the parlance of viability theory. To our best knowledge, this way of modelling the atherosclerosis progression is original. We compute two viability kernels, each for a different statin-treatment dose. Each kernel is composed of the vector [age, IMT] from which the disease can be restrained. By extension, the disease can’t be restrained from the kernel complements, this being mainly because of the disease and patient-age advancement. The kernels visualise tradeoffs between early and late treatments, which helps the clinician to decide when to start the statin treatment and which statin dose may be sufficient.

Primary Prevention of Cardiovascular Risk in Octogenarians by Risk Factors Control

Primary prevention of cardiovascular events in older adults is a relevant problem, due to lack of evidence for safe and efficacious therapy, its costs and elderly quality of life, Italy’s aging population is constantly increasing, so cardiovascu-lar disease (CVD) primary prevention in the elderly is a prime objective. Life expectancy has dramatically increased over the last 2 decades, the proportion of individuals aged 80 years and older has grown rapidly in Europe and the United States, but cost / effective ratio of CVD prevention through risk factors control is debated. It is therefore important to implement cardio-vascular risk factors estimation in the elderly to maximize the quality of life of patients and to lengthen their healthy life ex-pectancy, choosing the better treatment for each patient sharing the choice with himself when it is possible, always remem-bering that elderly patients often have multiple co-morbidities that require a high number of concurrent medications; this may increase the risk for drug-drug interactions, thereby reducing the potential benefits of CVD prevention therapy. Nevertheless, CVD is not an inevitable concomitant of aging. Sometimes, autopsy in the elderly reveals atheroma-free coronary arteries, a normal-sized heart and unscarred valves. All primary prevention strategy decisions should consider estimated life expectancy and overall function and not just the cardiovascular event risks, magnitude and time to benefit or harm, potentially altered ad-verse effect profiles, and informed patient preferences. CVD primary prevention needs to be more implemented in the elder-ly, this might contribute to improve health status and quality of life in this growing population if correctly performed.

Association of total cholesterol with severe acute pancreatitis: A U-shaped relationship

BACKGROUND & AIMS

There is no consensus on relationship between total cholesterol levels and incidence of severe acute pancreatitis (SAP). The aim of this study was to investigate the relation between total cholesterol (TC) and the disease severity of acute pancreatitis.

METHODS

We conducted a cross-sectional study on patients with acute pancreatitis between April 2012 and December 2015 in a university hospital. Fasting blood total cholesterol (TC) was assayed within 24 h of admission, as well as 3-5 days, 7-9 days and 13-15 days during hospitalization. Time interval before admission, age, gender, Body Mass Index, hypertension, diabetes mellitus, alcohol consumption, smoking, etiology and albumin were recorded as potential confounding factors. To assess the pattern of relationship of TC and SAP, we used restricted cubic spline analysis with multivariable logistic regression analysis. We also compared total cholesterol concentrations between patients with or without SAP at different time points.

RESULTS

648 patients (median age: 47.5 years; 62.4% man) were enrolled. The incidence of SAP was 10%. A U-shaped association of TC level within 24 h of admission with severity was observed in acute pancreatitis. Patients with low TC levels (<160 mg/dL) and high TC levels (>240 mg/dL) had a significantly higher incidence of SAP and protracted hospital stays when compared to moderate TC levels (160-240 mg/dL). Low total cholesterol levels (OR 2.72; 95 %eCI 1.27-5.83; P = 0.01) and high total cholesterol levels (OR 2.54; 95 %eCI 1.09-5.89; P = 0.03), were still independently associated with development of SAP after adjusting for potential confounding factors. Longitudinal cohort study indicated that patients with SAP had lower total cholesterol concentrations among 3-15 days after admission compared to patients without SAP (P < 0.001).

CONCLUSIONS

Both low TC level (<160 mg/dL) and high TC (>240 mg/dL) within 24 h of admission is independently associated with an increased risk of SAP.

Ezetimibe Lipid-Lowering Trial on Prevention of Atherosclerotic Cardiovascular Disease in 75 or Older (EWTOPIA 75)

Background:

Evidence regarding the primary prevention of coronary artery disease events by low-density lipoprotein cholesterol (LDL-C) lowering therapy in older individuals, aged ≥75 years, is insufficient. This trial tested whether LDL-C–lowering therapy with ezetimibe is useful for the primary prevention of cardiovascular events in older patients.

Methods:

This multicenter, prospective, randomized, open-label, blinded end-point evaluation conducted at 363 medical institutions in Japan examined the preventive efficacy of ezetimibe for patients aged ≥75 years, with elevated LDL-C without history of coronary artery disease. Patients, who all received dietary counseling, were randomly assigned (1:1) to receive ezetimibe (10 mg once daily) versus usual care with randomization stratified by site, age, sex, and baseline LDL-C. The primary outcome was a composite of sudden cardiac death, myocardial infarction, coronary revascularization, or stroke.

Results:

Overall, 3796 patients were enrolled between May 2009 and December 2014, and 1898 each were randomly assigned to ezetimibe versus control. Median follow-up was 4.1 years. After exclusion of 182 ezetimibe patients and 203 control patients because of lack of appropriate informed consent and other protocol violations, 1716 (90.4%) and 1695 (89.3%) patients were included in the primary analysis, respectively. Ezetimibe reduced the incidence of the primary outcome (hazard ratio [HR], 0.66; 95% CI, 0.50–0.86; P =0.002). Regarding the secondary outcomes, the incidences of composite cardiac events (HR, 0.60; 95% CI, 0.37–0.98; P =0.039) and coronary revascularization (HR, 0.38; 95% CI, 0.18–0.79; P =0.007) were lower in the ezetimibe group than in the control group; however, there was no difference in the incidence of stroke, all-cause mortality, or adverse events between trial groups.

Conclusions:

LDL-C–lowering therapy with ezetimibe prevented cardiovascular events, suggesting the importance of LDL-C lowering for primary prevention in individuals aged ≥75 years with elevated LDL-C. Given the open-label nature of the trial, its premature termination and issues with follow-up, the magnitude of benefit observed should be interpreted with caution.

Clinical Registration:

URL: https://www.umin.ac.jp . Unique identifier: UMIN000001988.

A Control-Theoretic Model of Atherosclerosis

We propose a control-theoretic aggregate model of the progression of atherosclerosis plaque, a chronic inflammatory disease of the arterial wall, to study the basic features of this disease. In the model, we exploit the role of inflammation in the disease progression, and use statins-drugs commonly recommended in atherosclerosis-to control this progression. We use a logistic function to allow for constrained growth of plaque. In the model, both the patient's age and overall health impact the plaque growth and its sensitivity to statins. The model parameters are estimated using original data, or calibrated using published research as well as our own clinical and laboratory studies. We contend that our model helps to gauge the statins' impact on a patient's plaque thickness, hence the disease's progression and cardiovascular risk, without requiring artery scans.

Serum total cholesterol and risk of cardiovascular and non-cardiovascular mortality in old age: a population-based study

Background

Whether the suggested inverse association between total cholesterol and mortality in old age varies according to cause of death and use of cholesterol medications remains to be elucidated. The aim of this study was to assess the associations of total cholesterol with cardiovascular and non-cardiovascular mortality in old age, and to explore whether their associations vary by use of cholesterol-lowering medications.

Methods

The study participants included 3090 older adults (age ≥ 60 years, 63.7% women) from a population-based cohort study, i.e., the Swedish National study on Aging and Care in Kungsholmen, Stockholm. At baseline (2001–2004), data on demographic factors, lifestyles, cardiovascular risk factors, use of medications, global cognitive function, mobility limitation, and apolipoprotein E genotype were collected through interviews, clinical examinations, laboratory tests as well as from the Swedish national patient register. Vital statistics data (e.g., date and causes of death) till December 31, 2011 for all participants were derived from Swedish cause of death register. Data were analyzed using Cox proportional hazards model for all-cause mortality and Fine-Gray competing risks regression model for cause-specific mortality controlling for multiple potential confounders.

Results

During 23,196 person-years of follow-up (median per person, 7.5 years), 1059 (34.3%) participants died. Compared to normal total cholesterol (<5.18 mmol/l), borderline-high (5.18–6.21 mmol/l) and high (≥6.22 mmol/l) total cholesterol were associated with a decreased risk of all-cause mortality, with the multiple-adjusted hazard ratio (95% confidence interval, CI) of 0.71 (0.61–0.83) and 0.68 (0.57–0.80), respectively (P for trend <0.001). The competing risk regression models revealed that the reduced all-cause mortality associated with high total cholesterol (≥6.22 mmol/l)) was mainly due to the reduced risk of non-cardiovascular mortality (hazard ratio = 0.67, 95% CI = 0.51–0.88). These associations were statistically evident only among individuals without use of cholesterol-lowering medications.

Conclusions

The inverse association between high total cholesterol and reduced all-cause mortality in older adults is primarily due to non-cardiovascular mortality, especially among those who are not treated with cholesterol-lowering medications.

Elevated high-sensitivity C-reactive protein as a risk marker of the attenuated relationship between serum cholesterol and cardiovascular events at older age. The ARIC Study

The relationship between cholesterol and coronary heart disease (CHD) is attenuated at older age. We analyzed cholesterol level as a predictor of CHD in 8,947 participants from the Atherosclerosis Risk in Communities (ARIC) Study, a large multicenter cohort study that enrolled participants in 1987-1989 at 4 field centers in Washington County, Maryland; Forsyth County, North Carolina; Jackson, Mississippi; and Minneapolis, Minnesota. Participants in the present analysis had no history of CHD and were stratified by age (<65 or ≥65 years) and high-sensitivity C-reactive protein (hs-CRP) level (<2 or ≥2 mg/L). Visit 4 (1996-1997) was the baseline for this analysis, with follow-up through 2008. Cholesterol level was significantly associated with CHD among younger participants, and cholesterol level was similarly predictive of CHD among older participants with an hs-CRP level of <2 mg/L. In contrast, among older participants with an hs-CRP level of 2 mg/L or higher, the association of CHD with total cholesterol level was borderline significant (hazard ratio = 1.14, 95% confidence interval: 1.00, 1.29), and the association of CHD with low-density lipoprotein cholesterol level was nonsignificant (hazard ratio = 1.10; 95% confidence interval: 0.96, 1.26). Among older persons with an elevated hs-CRP level, cholesterol level was significantly less predictive of CHD (P < 0.05), whereas for those with an hs-CRP level of <2 mg/L, there was no significant difference compared with younger participants. In conclusion, we found that among the young-old, the association of cholesterol level with CHD was strong when hs-CRP level was not elevated and weak when hs-CRP level was elevated. Therefore, hs-CRP level could be useful for stratifying the young-old to assess the strength of cholesterol level in CHD risk prediction.

Association of cardiovascular burden with mobility limitation among elderly people: a population-based study

Background

Cardiovascular risk factors (CRFs) such as smoking and diabetes have been associated with mobility limitations among older adults. We seek to examine to what extent individual and aggregated CRFs and cardiovascular diseases (CVDs) are associated with mobility limitation.

Methods

The study sample included 2725 participants (age ≥60 years, mean age 72.7 years, 62% women) in the Swedish National Study on Aging and Care in the Kungsholmen district of central Stockholm, Sweden, who were living either at their own home or in institutions. Data on demographic features, CRFs, and CVDs were collected through interview, clinical examination, self-reported history, laboratory tests, and inpatient register. Mobility limitation was defined as walking speed <0.8 m/s. Data were analyzed using multiple logistic models controlling for potential confounders.

Results

Of the 2725 participants, 581 (21.3%) had mobility limitation. The likelihood of mobility limitation increased linearly with the increasing number of CRFs (i.e., hypertension, high C-reactive protein, obesity, diabetes and smoking) (p for linear trend<0.010) and of CVDs (i.e., ischemic heart disease, atrial fibrillation, heart failure and stroke) (p for linear trend<0.001). There were statistical interactions of aggregated CRFs with age and APOE ε4 allele on mobility limitation (p_interaction<0.05), such that the association of mobility limitation with aggregated CRFs was statistically evident only among people aged <80 years and among carriers of the APOE ε4 allele.

Conclusion

Aggregations of multiple CRFs and CVDs are associated with an increased likelihood of mobility limitation among older adults; however the associations of CRFs with mobility limitation vary by age and genetic susceptibility.

Spiritual activation in very elderly individuals assessed as heart rate variability and plasma IL/10/IL-6 ratios

Proinflammatory cytokine responses might occur in elderly individuals with cardiovascular (CV) disease, cerebro-vascular (CVA) disease, and/or pulmonary disease (PD). Spiritual activation is an important coping mechanism, since psychiatric depression is an important risk factor for these individuals. Thirty-three very elderly individuals (87 ± 8 years) with previous CVD, CVA and/or PD participated in weekly 30 minute sermons by chaplains for over 20 months of chaplain liturgy (CL group). All underwent Holter ECG during the procedures and cardiac autonomic activities were assessed by maximum entropy analysis. Plasma IL-10 and IL-6 levels were compared with 26 age-matched (85 ± 10 years) individuals who did not participate in these activities (non-CL group). Both high frequency (HF) and pNN50 of heart rate variability (HRV) were higher in the CL group than in the non-CL group (HF, 190 ± 55 versus 92 ± 43 nu, P < 0.05; pNN50, 10.5 ± 16% versus 3.6 ± 3.8%, P < 0.05), whereas LF/HF was lower (1.4 ± 1.5 versus 2.2 ± 2.8, P < 0.05). Levels of IL-10/IL-6 were higher in the CL group (3.96 ± 5.0 versus 1.79 ± 1.6, P < 0.05). Hospitalization rates due to CVD and/or PD were lower in the CL group than in the non-CL group (4/33 versus 11/26, P < 0.05). We conclude that spiritual activation can modify proinflammatory cytokines and suppress CVD, CVA and/or PD via vagal modifications. Spiritual activation might be helpful for health in these very elderly individuals.

Low-dose nonlinear effects of smoking on coronary heart disease risk

Some recent discussions of adverse human health effects of active and passive smoking have suggested that low levels of exposure are disproportionately dangerous, so that "The effects of even brief (minutes to hours) passive smoking are often nearly as large (averaging 80% to 90%) as chronic active smoking" (Barnoya and Glantz, 2005). Recent epidemiological evidence (Teo et al., 2006) suggests a more linear relation. This paper reexamines the empirical relation between self-reported low levels of active smoking and risk of coronary heart disease (CHD) in public-domain data from the National Health and Nutrition Examination Survey (NHANES). Consistent with biological evidence on J-shaped and U-shaped relations between smoking-associated risk factors and CHD risks, we find that low levels of active smoking do not appear to be associated with increased CHD risk. Several methodological challenges in epidemiology may explain how model-derived estimates can predict low-dose linear or concave dose-response estimates, even if the empirical (i.e., data-based) relation does not show a clear increased risk at the lowest doses.

Impairments in activities of daily living in older Japanese men in hawaii and Japan

Introduction. Hypertension and cigarette smoking are dominant risk factors for cardiovascular disease in Japan while in westernized countries, broader effects encompass obesity, diabetes, and hypercholesterolemia. This paper examines whether different associations also appear important in the manifestation of activities of daily living (ADL) in older Japanese men in Hawaii and Japan. Methods. Measures of ADL (feeding, toileting, dressing, bathing, and walking around the house) were assessed from 1995 to 1999 in 1,893 men in Hawaii and 543 men in Japan. Concomitant risk factors were measured from 1990 to 1993. Results. In Hawaii, diabetes increased the odds of ≥1 ADL impairment nearly 1.5-fold (P = .020). A similar association was absent in Japan. In contrast, the odds of an ADL impairment in Japan was increased more than 5-fold in the presence of stroke (P < .001). The association in Hawaii was significantly weaker (P = .007). In both cohorts, past alcohol use was associated with a greater likelihood of ADL impairment. Conclusion. In this comparison of genetically similar samples, findings suggest that different strengths in risk factor associations with cardiovascular disease in Japan and westernized countries may also include different strengths in associations with impaired ADL.

Prognostic significance of serum cholesterol, lathosterol, and sitosterol in old age; a 17-year population study

BACKGROUND. Low serum total cholesterol is frequently associated with worse survival in older people, but mechanisms of this association are poorly understood. AIMS. Characteristics of cholesterol metabolism were related to survival in a random 75 + population sample. METHODS. Serum cholesterol and lathosterol, and sitosterol were measured in random persons (n = 623) of birth cohorts (1904, 1909, and 1914) in 1990, and all persons were followed for 17 years. RESULTS. Total cholesterol declined in old age, and low cholesterol was associated with poor health and multi-morbidity. Cholesterol below 5.0 mmol/L was associated with accelerated all-cause mortality (age- and gender-adjusted hazard ratio (HR) 1.54; 95% CI 1.21-1.97; P < 0.001) and vascular mortality (HR 2.13 (1.42-3.07); P < 0.001). Lathosterol (indicating cholesterol synthesis) and sitosterol (indicating cholesterol absorption) also decreased with deteriorating health. Low lathosterol, sitosterol, and cholesterol predicted mortality additively and independently of each other. When all three sterols were high (> median) or low, the age- and gender-adjusted survival was 9.9 and 5.6 years (P < 0.001). CONCLUSION. Lower synthesis and absorption of cholesterol, and low serum cholesterol level are associated with deteriorating health and indicate impaired survival in old age.

[Chronic low-grade inflammation, lipid risk factors and mortality in functionally dependent elderly]

BACKGROUND/AIM

It has been proved that a highly sensitive C-reactive protein (hsCRP) can be used as an established marker of chronic inflammation for cardiovascular risk assessment. Since mean values of both low-density cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) decrease during aging, the knowledge that increased hsCRP concentration predicts mortality (Mt) would influence therapy and treatment outcome. The aim of this study was to examine importance of chronic low grade inflammation and its association with lipid risk factors for all-cause Mt in functionally dependent elderly.

METHODS

The participants of this longitudinal prospective study were 257 functionally dependent elderly aged 65-99 years. Baseline measurements: anthropometric measurements, blood pressure, fasting plasma total cholesterol (TC), triglyceride (TG), HDL-C, LDL-C, non-HDL-C, hemoglobin Alc (HbA1c) were recorded and different lipid ratios were calculated. Inflammation was assessed by the levels of white blood cells, fibrinogen and hsCRP. The participants with hsCRP grater than 10 mg/L were excluded from the study. The residual participants (77.4% women) were divided into three groups according to their hsCRP levels: a low (< 1 mg/L, n=70), average (1 to 3 mg/L, n=69), and high (3-10 mg/L, n=69) hsCRP group. Associations of all-cause Mt with different risk factors were examined using logistic regression analysis.

RESULTS

The hsCRP level showed a significant positive correlation with waist (r = 0.199, p = 0.004) and hip (r = 0.187, p = 0.007) circumferences, body mass index (r = 0.143, p = 0.040) and serum triglyceride level (r = 0.139, p = 0.045) and significant negative correlation with HDL-C (r = -0.164, p = 0.018). Ratios TC/HDL-C and TG/HDL-C were significantly smaller in the low hsCRP group compared to the average hsCRP group (p = 0.019,p = 0.045, respectively) and without significant differences compared with the high hsCRP group. Two years after the baseline examination 22.1% participants died from all-cause Mt. After adjustment for other risk factors, a TC was significantly associated with all-cause Mt only in high hsCRP group: Odds ratio (OR) = 3.71 (95% confidence interval-CI: 1.09-12.63).

CONCLUSIONS

In this study a high hsCRP was an important factor to identify functionally dependent elderly at high risk who may have more benefit from agressive lipid lowering treatment.

Nosocomial mortality and early prediction of patients with severe acute pancreatitis

BACKGROUND AND AIMS

The aim of this study is to analyze factors (especially serum total cholesterol) that can enable early prediction of in-hospital mortality of patients with severe acute pancreatitis (SAP).

METHODS

Predictive factors (especially serum total cholesterol) for in-hospital mortality were evaluated retrospectively from the clinical data obtained from 338 SAP patients in our hospital from January 1999 to January 2008, who underwent intensive care, blood routine, blood biochemical tests and even computed tomography at the time of admission.

RESULTS

This analysis revealed that within 24 h after admission, serum total cholesterol (TC) was a mortality-reduced factor when it is between 4.37 mmol/L and 5.23 mmol/L (P < 0.05). Evaluated TC was accompanied by decreased C-reactive protein (CRP). CRP > 170 mg/L and albumin (ALB) < 30 g/L increased the fatal outcome (P < 0.05). Low albumin was a stronger predictor than CRP.

CONCLUSIONS

Within 24 h after admission, moderate elevation of TC level seemed to increase the resistance to inflammation and hence improved the survival rate in patients with SAP, and reduced the in-hospital mortality. Inflammatory reaction (with or without infection), hypoalbuminemia and TC were prognostic factors for in-hospital mortality; both high levels of CRP and low ALB levels were associated with in-hospital mortality in patients with SAP.

Serum lipids and their association with mortality in the elderly: a prospective cohort study

BACKGROUND AND AIMS

To determine whether high levels of serum total cholesterol and low levels of high-density lipoprotein cholesterol (HDLc) are associated with increased mortality in the elderly.

METHODS

Prospective cohort study of 1032 non-institutionalized people aged 70 in the city of Turku, Southern Finland. The cohort population was recruited as part of a larger longitudinal aging study, the Turku Elderly Study. Fasting serum levels of total cholesterol, HDL-c and triglycerides were measured, and the amount of low-density lipoprotein cholesterol was calculated at baseline. The cohort was followed for mortality for 12 years, and the causes of death were recorded and further classified into cardiovascular and other causes of death. The hazard ratios of dying for subjects in various cholesterol quartiles were computed by the Cox proportional hazards model, adjusting for cardiovascular risk factors and pre-existing medical conditions.

RESULTS

Low levels of serum total cholesterol and HDL-c were associated with a greater risk of death over a follow-up of 12 years. After adjustment for several cardiovascular risk factors, the association between total cholesterol and survival changed. All-cause mortality seemed to be highest in the highest quartile of total cholesterol and nearly as high in the lowest quartile of total cholesterol, suggesting a U-shaped connection, but the differences were not statistically significant. However, cardiovascular mortality was significantly lowest in the lowest quartile of total cholesterol and significantly highest in the lowest quartile of HDL-c.

CONCLUSIONS

High levels of serum total cholesterol and particularly low levels of HDL-c seem to be risk factors for cardiovascular mortality even in the elderly population.

[Quality of care among older adults with diabetes mellitus: comparison between community-dwelling adults attended to by home care services and nursing home residents in Dresden]

Due to changes in the age structure of the population the number of frail elderly diabetics is rising. This change is accompanied by an increase in nursing care efforts and requirements in both home care services and nursing homes. The aim of this study was to evaluate the quality of care in the home care and nursing home setting concerning the structure, the process and the outcome quality at the institutional and patient level. This is an observational transversal study. At the institutional level a standardised questionnaire of the German Diabetes Research Institute was sent to all nursing homes (37) and home care services (88) in Dresden. At the patient level 37 homebound patients and 46 residents were recruited. A Geriatric assessment and a clinical examination were performed and a blood sample was analysed. Patients with moderate or severe cognitive impairment were excluded. The prevalence of diabetes in home care services was 27.2% and in nursing homes 36.1%. The participation rate among the institutions was 21.6% (n = 27). In 14% (n = 12) of the diabetic patients the HbA1c was above 8% (poor metabolic control) and in 24% (20) it was between 7% and 8% (regular metabolic control). 56.6% (n = 21) of the homebound elderly diabetics and 46.7% (n = 21) of the nursing home residents with diabetes were hospitalized at least once during the last 12 months. Our study showed a high prevalence of diabetes in both types of institutions in Dresden and a high hospitalisation rate of the elderly diabetics, although 62% of the patients had an optimum metabolic control. These facts indicate that the quality of care of frail elderly diabetics concerning the multimorbidity might be further improved.

Apolipoprotein B and non-high density lipoprotein cholesterol and the risk of coronary heart disease in Chinese

The aim of our study was to compare apolipoprotein B (apoB), non-high density lipoprotein cholesterol (nonHDL-C), low density lipoprotein cholesterol (LDL-C), and other lipid markers as predictors of coronary heart disease (CHD) in Chinese. Overall, 122 individuals developed CHD during a median 13.6 years of follow-up in 3,568 adult participants from a community-based cohort. The multivariate relative risk of CHD in the highest quintile compared with the lowest quintile was 2.74 [95% confidence interval (CI), 1.45-5.19] for apoB, 1.98 (95% CI, 1.00-3.92) for nonHDL-C, and 1.86 (95% CI, 1.00-3.49) for LDL-C (all tests for trend, P < 0.05). ApoB also had the highest receiver operator characteristic curve area (0.63; 95% CI, 0.58-0.68) in predicting CHD. When apoB and nonHDL-C were mutually adjusted, only apoB was predictive; the relative risk was 2.80 (95% CI, 1.31-5.96; P = 0.001) compared with 1.09 (95% CI, 0.49-2.40; P = 0.75) for nonHDL-C. Compared with the lowest risk, participants with the highest apoB and total cholesterol/HDL-C had a 3-fold increased risk of developing CHD (relative risk = 3.21; 95% CI, 1.45-7.14). These data provide strong evidence that apoB concentration was a better predictor of CHD than other lipid markers in Chinese.

Health status, blood and anthropometrical indices from Greek old and nonagenarian subjects

As the elderly population is increasing rapidly, there is a lot of scientific interest in clarifying the differential life-style, genetic, biochemical and molecular factors contributing to mortality or exceptional longevity. Within the framework of the ZINCAGE project, 249 old (60-85 years) and nonagenarian Greek subjects (>/=85 years old) were recruited and anthropometrical, blood and biochemical indices as well as blood pressure measurements were obtained. Based upon the inclusion criteria, 214 of them were characterized as healthy (136 female, 78 male), while those characterized as non-healthy were excluded from the statistical analysis. The findings indicated an 88.4% prevalence of overweight and obesity in elderly (91.2% in women, 83.3% in men), while a significant decrease in body mass index with age was recorded. Hypercholesterolemia was observed in 75.3% of elderly women and in 69.2% of men. Erythrocyte sedimentation rate value was increased in 27.6% of all healthy elderly, while zinc deficiency was observed in 18.7% of elderly. Over 85.0% of all healthy elderly were within normal range for all other hematological analysis. Blood analysis confirmed the good health status of the elderly recruited as healthy, except for the high prevalence of obesity and hypercholesterolemia.

Relation between plaque progression and low-density lipoprotein cholesterol during aging as assessed with serial long-term (> or =12 months) follow-up intravascular ultrasound of the left main coronary artery

Because of the clinical benefit of lipid lowering in older patients, we hypothesized that the relation between low-density lipoprotein (LDL) cholesterol serum levels and coronary plaque progression may persist throughout aging. We analyzed serial intravascular ultrasound (IVUS) data of 60 left main stems (18 +/- 9 months apart) and evaluated the relation between LDL cholesterol levels and coronary plaque progression at different ages. The population (n = 60) was divided into 3 groups according to age: tertile 1 (n = 20) was a mean age of 48 +/- 6 years (median 51, range 33 to 55), tertile 2 (n = 20) was a mean age of 58 +/- 2 years (median 59, range 55 to 61), and tertile 3 (n = 20) was a mean age of 66 +/- 6 years (median 65, range 61 to 83). Between groups, there was no significant difference in non-age-related demographics, clinical data, lipid profiles, or medications (e.g., statins). There was a positive linear relation between LDL cholesterol and annual changes in plaque plus media area in all age tertiles, which was statistically significant in tertiles 2 and 3 (r = 0.56, p <0.01; r = 0.50, p <0.02) and showed a strong trend in tertile 1 (r = 0.41, p = 0.07). The estimated LDL cholesterol thresholds, which, as determined by regression analysis, would correspond to no plaque progression, were 74, 60, and 78 mg/dl, respectively, in tertiles 1, 2, and 3. In conclusion, serial IVUS data in left main coronary arteries suggest that the relation between LDL cholesterol serum levels and plaque progression persists during aging.

Relation of serum total cholesterol, C-reactive protein levels, and statin therapy to survival in heart failure

Although increased cholesterol levels predict mortality in patients with coronary artery disease, it is unclear whether hypercholesterolemia is associated with adverse survival in patients with heart failure. A cohort of subjects derived from the Intermountain Heart Collaborative Study Registry (1993 to 2003) who had ejection fractions < or = 40% or clinical diagnoses of heart failure and long-term follow-up for death were studied (n = 1,646). Total cholesterol (TC) was divided into quartiles: quartile 1, < 141.3 mg/dl; quartile 2, 141.3 to 167.9 mg/dl; quartile 3, 168.0 to 201.0 mg/dl; and quartile 4, > 201.0 mg/dl. Multivariate Cox regression models were used to evaluate the associations of cholesterol, statin therapy, and C-reactive protein to mortality. The mean age was 65.5 years; 65% of the subjects were men and 65% had coronary artery disease. Although 53% were using statins, statin use was not different across TC quartiles. Average time to death was 2.4 years (maximum 10). Mortality for quartile 4 versus quartile 1 was not different (hazard ratio [HR] 1.12, p = 0.52); mortality was reduced for quartile 3 versus quartile 1 (HR 0.66, p = 0.027) and tended to be reduced for quartile 2 versus quartile 1 (HR 0.77, p = 0.14). Subanalysis of patients not using statins (n = 737, death = 20.2%) found no association between TC and survival (for quartile 3 vs quartile 1, HR 0.97, p = 0.89), but for patients using statins (n = 848, death = 16.3%), the effect was even greater for quartile 3 versus quartile 1 (HR 0.40, p = 0.002) than in the overall population. Nonsurvivors had higher levels of C-reactive protein than survivors. In conclusion, elevated TC appears to be associated with improved survival. The effect was stronger in patients receiving statin therapy, but the cause of this differential effect is uncertain.

How well does the metabolic syndrome defined by five definitions predict incident diabetes and incident coronary heart disease in a Chinese population?

We evaluate the ability of the metabolic syndrome (MetS) defined by five definitions for predicting both incident CHD and diabetes combined, diabetes alone, and CHD alone in a Chinese population. The screening survey for type 2 diabetes was conducted in 1994. A follow-up study of 541 high-risk non-diabetic individuals who were free of CHD at baseline was carried out in 1999 in Beijing area. The MetS was defined by the World Health Organization (WHO), European Group for the Study of Insulin Resistance (EGIR), American College of Endocrinology (ACE), the International Diabetes Federation (IDF), and the National Cholesterol Education Program and the American Heart Association (AHA) (updated NCEP) criteria. From a multiple logistic regression adjusting for age, sex, education, occupation, smoking, family history of diabetes, and total cholesterol, the relative risk of the ACE-defined MetS for incident diabetes alone (67 cases) was 2.29 (95% CI, 1.20-4.34). The MetS defined by the five definitions was associated with a 1.8-3.9 times increased risk for both incident CHD and diabetes combined (59 cases), and with a 1.9-3.0 times for total incident diabetes (126 cases). None of the five definitions predicted either incident CHD alone (177 cases) or total incident CHD (236 cases). In conclusion, the MetS defined by the current definitions appears to be more effective at predicting incident diabetes.