Risk factors for ischaemic heart disease: the prospective phase of the British Regional Heart Study

The Impact of Smoking Status 1 Year After ST-Segment Elevation Myocardial Infarction on Cardiovascular Events and Mortality in Patients Aged ≤60 Years

Smoking is associated with increased risk for acute ST-elevation myocardial infarction (STEMI) at a young age. Although smoking is a modifiable risk factor, smoking cessation rates after STEMI are suboptimal. We investigated the association between smoking status 1 year after STEMI and adverse events in patients (n = 765) aged ≤60 years. Patients were categorized as: (1) nonsmokers, (2) quit smoking, and (3) continued/resumed smoking. The association between smoking status and risk for major adverse cardiovascular events (MACEs) was analyzed during a median follow-up of 8 years. At presentation with STEMI, the mean age was 51 ± 7 years (88% men) and 427 (56%) were smokers. A year after STEMI, 272 continued smoking, 35 quit but later resumed smoking (summed to a single group; n = 307), and 120 quit smoking. Continued smoking was associated with younger age, male gender, lower weight, and low socioeconomic status. Compared with nonsmokers, the adjusted hazard ratio (95% confidence interval) for myocardial infarction, stroke, unstable angina, death, and MACE was 2.51 (1.67 to 3.73), 2.07 (0.94 to 4.56), 3.73 (1.84 to 7.58), 2.52 (1.53 to 4.13), and 2.40 (1.80 to 3.22), accordingly, in those who continued to smoke. However, the adjusted hazard ratio was not significantly associated with these outcomes in patients who quit smoking (MACE: 1.20 [0.77 to 1.87], p=0.414; nonsignificant for individual end points). In conclusion, the prevalence of smoking in young and middle-aged patients presenting with STEMI is high and smoking cessation rates are low. A year after STEMI, those who continued to smoke had worse cardiovascular outcomes and death compared with nonsmokers; however, the long-term outcomes among those who quit smoking appear to be comparable with nonsmokers. The results highlight the contrast between health benefits of quitting smoking after STEMI and low abstinence rates in clinical practice.

Targeting Smad-Mediated TGFß Pathway in Coronary Artery Bypass Graft

Revascularization surgeries such as coronary artery bypass grafting (CABG) are sometimes necessary to manage coronary heart disease (CHD). However, more than half of these surgeries fail within 10 years due to the development of intimal hyperplasia (IH) among others. The cytokine transforming growth factor-beta (TGFß) and its signaling components have been found to be upregulated in diseased or injured vessels, and to promote IH after grafting. Interventions that globally inhibit TGFß in CABG have yielded contrasting outcomes in in vitro and in vivo studies including clinical trials. With advances in molecular biology, it becomes clear that TGFß exhibits both protective and damaging roles, and only specific components such as some Smad-dependent TGFß signaling mediate vascular IH. The activin receptor-like kinase (ALK)-mediated Smad-dependent TGFß signaling pathways have been found to be activated in human vascular smooth muscle cells (VSMCs) following injury and in hyperplastic preimplantation vein grafts. It appears that focused targeting of TGFß pathway constitutes a promising therapeutic target to improve the outcome of CABG. This study dissects the role of TGFß pathway in CABG failure, with particular emphasis on the therapeutic potentials of specific targeting of Smad-dependent and ALK-mediated signaling.

Correlation without a cause: an epidemiological odyssey

In the 1980s debate intensified over whether there was a protective effect of high-density lipoprotein cholesterol (HDL-C) or an adverse effect of triglycerides on coronary heart disease (CHD) risk. In a 1991 paper reprinted in the IJE we suggested that the high degree of correlation between the two, together with plausible levels of measurement error, made it unlikely that conventional epidemiological approaches could contribute to causal understanding. The consensus that HDL-C was protective, popularly reified in the notion of ‘good cholesterol’, strengthened over subsequent years. Reviewing the biostatistical and epidemiological literature from before and after 1991 we suggest that within the observational epidemiology pantheon only Mendelian randomization studies—that began to appear at the same time as the initial negative randomized controlled trials—made a meaningful contribution. It is sobering to realize that many issues that appear suitable targets for epidemiological investigation are simply refractory to conventional approaches. The discipline should surely revisit this and other high-profile cases of consequential epidemiological failure—such as that with respect to vitamin E supplementation and CHD risk—rather than pass them over in silence.

Clinical, Angiographic Characteristics and In-Hospital Outcomes of Smoker and Nonsmoker Patients After Primary Percutaneous Coronary Intervention

BACKGROUND

Smoking is a well-established cardiac risk factor there is dearth of Local data regarding clinical and angiographic characteristics of smoker patients.

OBJECTIVES

This study was planned to assess the differences in the clinical characteristics, angiographic characteristics, and in-hospital outcomes of smokers and nonsmokers after primary percutaneous coronary intervention at a tertiary care hospital in Karachi, Pakistan.

METHODS

We included patients between 40 and 80 years of age diagnosed with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention from July 1, 2017, to March 31, 2018. Clinical and angiographic characteristics and in-hospital outcomes were obtained from the cases submitted to the National Cardiovascular Data Registry's CathPCI (Catheterization-Percutaneous Coronary Intervention) Registry from our site.

RESULTS

A total of 3,255 patients were included in this study. Smokers consist of 25.1% (817) of the total sample. A high majority of smokers were male, 98.8% (807), and smokers were relatively younger as compared to nonsmokers with a mean age of 52.89 ± 10.59 versus 55.98 ± 11.24 years; p < 0.001. Smokers had higher post-procedure TIMI (Thrombolysis In Myocardial Infarction) flow grade III: 97.8% (794) versus 95.53% (2,329); p = 0.037, and they had a relatively low mortality rate: 2.69% (22) versus 3.16% (77); p = 0.502.

CONCLUSIONS

Smokers were predominantly male and around 3 years younger than nonsmokers. Diabetes mellitus and hypertension were less common among smokers and single-vessel disease was the more common angiographic finding for smokers as compared to 3-vessel disease for nonsmokers. No statistically significant differences in in-hospital outcomes were observed. ST-segment elevation myocardial infarction in smokers despite younger age and the low atherosclerotic risk profile, in our region, emphasize the need for nicotine addiction management and smoking cessation campaigns at large and for pre-discharge counseling.

Is smokeless tobacco a risk factor for coronary heart disease? A systematic review of epidemiological studies

BACKGROUND

There is on-going debate about the wisdom of substituting smokeless tobacco products for cigarette smoking as a 'harm reduction' strategy. It is generally believed that health risks associated with smokeless tobacco use (ST) are lower than those with cigarette smoking. However, the population attributable risk of smoking is higher for cardiovascular diseases than for any cancers, and few studies or reviews have considered the cardiovascular outcomes of ST use. A systematic review was therefore carried out to highlight the gaps in the evidence base.

METHODS

Electronic databases were searched, supplemented by screening reference lists, smoking-related websites, and contacting experts. Analytical observational studies of ST use (cohorts, case-control, cross-sectional studies) were included if they reported on cardiovascular disease (CVD) outcomes, or risk factors. Data extraction covered control of confounding, selection of cases and controls, sample size, clear definitions and measurements of the health outcome and ST use. One or two independent reviewers carried out selection, extraction and quality assessments.

RESULTS

A narrative review was carried out. Very few studies were identified; only three from Sweden consider CVD outcomes and these are discrepant. There may be a modest association between use of Swedish snuff (snus) and cardiovascular disease (e.g., relative risk=1.4, 95% confidence interval 1.2-1.6) in one prospective cohort study. Several other studies have considered associations between ST use and intermediate outcomes (CVD risk factors).

CONCLUSIONS

There may be an association between ST use and cardiovascular disease. However, further rigorous studies with adequate sample sizes are required.

Harnessing the Power of Difference: Colonialism and British Chronic Disease Research, 1940-1975

Recent studies of post-war chronic disease epidemiology have generally focused on the histories of research in the USA and UK. Using the archival records of a major British funding body, the Colonial Medical Research Committee and its successor the Tropical Medical Research Board, this article demonstrates the advantages of bringing a post-colonial analytic to this historiography. It highlights how the administrative and medical interests in population difference at the centre of the new epidemiology came to map onto political apparatus initially created to know, reform and govern colonial subjects. Although detached from imperial aims, British medical scientists nonetheless attached value to colonial populations on the basis of British benefit and turned various sites into laboratories to extract it. This relationship did not die with the end of imperial rule. British scientists continued to pursue chronic disease epidemiology in former colonies well into the post-war period, informing debates about Britain's own public health concerns.

Long-term smoking cessation and heart rate dynamics in an aging healthy cohort: Is it possible to fully recover?

AIM

To evaluate the long-term influence of smoking cessation on the regulation of the autonomic cardiovascular system in an aging general population, using the subpopulation of lifelong non-smokers as control group.

METHODS

We analyzed 1481 participants aged ≥50 years from the SAPALDIA cohort. In each participant, heart rate variability and heart rate dynamics were characterized by means of various quantitative analyzes of the inter-beat interval time series generated from 24-hour electrocardiogram recordings. Each parameter obtained was then used as the outcome variable in multivariable linear regression models in order to evaluate the association with smoking status and time elapsed since smoking cessation. The models were adjusted for known confounding factors and stratified by the time elapsed since smoking cessation.

RESULTS

Our findings indicate that smoking triggers adverse changes in the regulation of the cardiovascular system, even at low levels of exposure since current light smokers exhibited significant changes as compared to lifelong non-smokers. Moreover, there was evidence for a dose-response effect. Indeed, the changes observed in current heavy smokers were more marked as compared to current light smokers. Furthermore, full recovery was achieved in former smokers (i.e., normalization to the level of lifelong non-smokers). However, while light smokers fully recovered within the 15 first years of cessation, heavy former smokers might need up to 15-25 years to fully recover.

CONCLUSION

This study supports the substantial benefits of smoking cessation, but also warns of important long-term alterations caused by heavy smoking.

Psychosocial interventions for smoking cessation in patients with coronary heart disease

BACKGROUND

This is an update of a Cochrane review previously published in 2008. Smoking increases the risk of developing atherosclerosis but also acute thrombotic events. Quitting smoking is potentially the most effective secondary prevention measure and improves prognosis after a cardiac event, but more than half of the patients continue to smoke, and improved cessation aids are urgently required.

OBJECTIVES

This review aimed to examine the efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease in short-term (6 to 12 month follow-up) and long-term (more than 12 months). Moderators of treatment effects (i.e. intervention types, treatment dose, methodological criteria) were used for stratification.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (Issue 12, 2012), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to January 2013. This is an update of the initial search in 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with CHD with a minimum follow-up of 6 months.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias. Abstinence rates were computed according to an intention to treat analysis if possible, or if not according to completer analysis results only. Subgroups of specific intervention strategies were analysed separately. The impact of study quality on efficacy was studied in a moderator analysis. Risk ratios (RR) were pooled using the Mantel-Haenszel and random-effects model with 95% confidence intervals (CI).

MAIN RESULTS

We found 40 RCTs meeting inclusion criteria in total (21 trials were new in this update, 5 new trials contributed to long-term results (more than 12 months)). Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors (eg. obesity, inactivity and smoking). The trials mostly included older male patients with CHD, predominantly myocardial infarction (MI). After an initial selection of studies three trials with implausible large effects of RR > 5 which contributed to substantial heterogeneity were excluded. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.13 to 1.32, I² 54%; abstinence rate treatment group = 46%, abstinence rate control group 37.4%), but heterogeneity between trials was substantial. Studies with validated assessment of smoking status at follow-up had similar efficacy (RR 1.22, 95% CI 1.07 to 1.39) to non-validated trials (RR 1.23, 95% CI 1.12 to 1.35). Studies were stratified by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The RRs for different strategies were similar (behavioural therapies RR 1.23, 95% CI 1.12 to 1.34, I² 40%; telephone support RR 1.21, 95% CI 1.12 to 1.30, I² 44%; self-help RR 1.22, 95% CI 1.12 to 1.33, I² 40%). More intense interventions (any initial contact plus follow-up over one month) showed increased quit rates (RR 1.28, 95% CI 1.17 to 1.40, I² 58%) whereas brief interventions (either one single initial contact lasting less than an hour with no follow-up, one or more contacts in total over an hour with no follow-up or any initial contact plus follow-up of less than one months) did not appear effective (RR 1.01, 95% CI 0.91 to 1.12, I² 0%). Seven trials had long-term follow-up (over 12 months), and did not show any benefits. Adverse side effects were not reported in any trial. These findings are based on studies with rather low risk of selection bias but high risk of detection bias (namely unblinded or non validated assessment of smoking status).

AUTHORS' CONCLUSIONS

Psychosocial smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient duration. After one year, the studies showed favourable effects of smoking cessation intervention, but more studies including cost-effectiveness analyses are needed. Further studies should also analyse the additional benefit of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone and investigate economic outcomes.

Antihyperlipidemic effect of Cyclocarya paliurus (Batal.) Iljinskaja extract and inhibition of apolipoprotein B48 overproduction in hyperlipidemic mice

ETHNOPHARMACOLOGICAL RELEVANCE

Cyclocarya paliurus (CP) Batal., the sole species in its genus, is a native plant to China. As a traditional Chinese folk medicine, the tree leaves have been widely used for the treatment of metabolic disorders, including hyperlipidemia, obesity, diabetes and hypertension.

AIM OF THE STUDY

The study aimed to evaluate the antihyperlipidemic effect of CP ethanol extract, as well as its inhibitory activity on apolipoproteinB48 (apoB48), in normal and hyperlipidemic mice.

MATERIALS AND METHODS

The antihyperlipidemic effect of CP was evaluated in hyperlipidemic mice induced by high-fat diet for 4 weeks. CP ethanol extract (0.37, 0.75 and 1.5g/kg/day) was orally administrated once daily. Lipids and antioxidant profiles, including total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px), together with the indices of hepatic and renal functions were examined. RT-qPCR and western blotting were used to analysis the expression levels of tumor necrosis factor (TNF-α), total- and triglyceride-rich apoB48 (TRL-apoB48), as well as the phosphorylation of the mitogen-activatein kinase (MAPK).

RESULTS

CP as well as simvastatin remarkably lowered the levels of TC, TG, LDL-C and MDA, and at the same time, elevated the HDL-C, SOD and GSH-Px in high-fat diet mice. It also decreased the serum concentration of total- and TRL-apoB48 in the fasting state. CP inhibited TNF-α expression and phosphorylation level of MAPK. Furthermore, the HE staining of liver and kidney, together with hepatic and renal function analysis showed hepato- and renoprotective activities of CP.

CONCLUSIONS

These results suggested that CP possesses beneficial potentials for use in treating hyperlipidemia and the underlying lipid-lowering mechanism might associate with a down-regulation of the intestinal-associated lipoprotein apoB48, which may provide evidence about its practical application for treating hyperlipidemia and its complications.

Carpal tunnel decompression in the super-elderly

There is conflicting evidence about the functional outcome and rate of satisfaction of super-elderly patients (≥ 80 years of age) after carpal tunnel decompression.

We compiled outcome data for 756 patients who underwent a carpal tunnel decompression over an eight-year study period, 97 of whom were super-elderly, and 659 patients who formed a younger control group (< 80 years old). There was no significant difference between the super-elderly patients and the younger control group in terms of functional outcome according to the mean (0 to 100) QuickDASH score (adjusted mean difference at one year 1.8; 95% confidence interval (CI) -3.4 to 7.0) and satisfaction rate (odds ratio (OR) 0.78; 95% CI 0.34 to 1.58). Super-elderly patients were, however, more likely to have thenar muscle atrophy at presentation (OR 9.2, 95% CI 5.8 to 14.6). When nerve conduction studies were obtained, super-elderly patients were more likely to have a severe conduction deficit (OR 12.4, 95% CI 3.0 to 51.3).

Super-elderly patients report functional outcome and satisfaction rates equal to those of their younger counterparts. They are more likely to have thenar muscle atrophy and a severe nerve conduction deficit at presentation, and may therefore warrant earlier decompression.

Cite this article: Bone Joint J 2014; 96-B:1234–8.

WITHDRAWN: Smoking cessation for the secondary prevention of coronary heart disease

BACKGROUND

Although the importance of smoking as a risk factor for coronary heart disease is beyond doubt, the speed and magnitude of risk reduction when a smoker with coronary heart disease quits are still subjects of debate.

OBJECTIVES

To estimate the magnitude of risk reduction when a patient with CHD stops smoking.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL) , MEDLINE, EMBASE, Science Citation Index, CINAHL, PsychLit, Dissertation Abstracts, BIDS ISI Index to Scientific and Technical Proceedings, UK National Research Register from the start of each database. Sixty-one large international cohort studies of cardiovascular disease were identified, and contact made with authors to search for any unpublished results. The search was supplemented by cross-checking references and contact with various experts. Date of last search was April 2003.

SELECTION CRITERIA

Any prospective cohort studies of patients with a diagnosis of CHD, which include all-cause mortality as an outcome measure. Smoking status must be measured on at least two occasions to ascertain which smokers have quit, and followed-up for at least two years.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed independently by two reviewers.

MAIN RESULTS

Twenty studies were included. There was a 36% reduction in crude relative risk (RR) of mortality for those who quit smoking compared with those who continued to smoke (RR 0.64, 95% confidence interval (CI) 0.58 to 0.71). There was also a reduction in non-fatal myocardial infarctions (crude RR 0.68, 95% CI 0.57 to 0.82). Many studies did not adequately address quality issues, such as control of confounding, and misclassification of smoking status. However, there was little difference in the results for the six 'higher quality' studies, and little heterogeneity between these studies. This review was not able to assess how quickly the risk of mortality was reduced.

AUTHORS' CONCLUSIONS

Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD. The pooled crude RR was 0.64 (95% CI 0.58 to 0.71). This 36% risk reduction appears substantial compared with other secondary preventive therapies such as cholesterol lowering which have received greater attention in recent years. The risk reduction associated with quitting smoking seems consistent regardless of differences between the studies in terms of index cardiac events, age, sex, country, and time period. However, relatively few studies have included large numbers of older people, women, or people of non-European descent, and most were carried out in Western countries.

Blood pressure in early adulthood, hypertension in middle age, and future cardiovascular disease mortality: HAHS (Harvard Alumni Health Study)

OBJECTIVES

We sought to examine the association of early adulthood blood pressure with cardiovascular disease (CVD) mortality, while accounting for middle-age hypertension.

BACKGROUND

Elevated blood pressure in middle age is an established CVD risk factor, but evidence for association with measurements earlier in life is sparse.

METHODS

The HAHS (Harvard Alumni Health Study) is a cohort study of 18,881 male university students who had their blood pressure measured at university entry (1914 to 1952; mean age 18.3 years) and who responded to a questionnaire mailed in either 1962 or 1966 (mean age 45.8 years) in which physician-diagnosed hypertension status was reported. Study members were subsequently followed for mortality until the end of 1998.

RESULTS

Following adjustment for age, body mass index, smoking, and physical activity at college entry, compared with men who were normotensive according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure criteria (<120/<80 mm Hg), there was an elevated risk of coronary heart disease (CHD) mortality (1,917 deaths) in those who were pre-hypertensive (120 to 139/80 to 89 mm Hg) (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 1.07 to 1.36), stage 1 (140 to 159/90 to 99 mm Hg) (HR: 1.46; 95% CI: 1.25 to 1.70), and stage 2 hypertensive (≥160/≥100 mm Hg) (HR: 1.89; 95% CI: 1.46 to 2.45), incremental across categories (p(trend) < 0.001). After additionally accounting for middle-age hypertension, estimates were somewhat attenuated, but the pattern remained. Similar associations were apparent for total and CVD mortality, but not stroke mortality.

CONCLUSIONS

Higher blood pressure in early adulthood was associated with elevated risk of all-cause mortality, CVD, and CHD, but not stroke, several decades later. Effects largely persisted after taking into account mediation by middle-age hypertension. Thus, the long-term benefits of blood pressure lowering in early adulthood are promising, but supporting trial data are required.

Risk factors for sudden and non-sudden coronary death

The impact of risk factors for sudden and non-sudden coronary death was investigated in 3,589 Finnish men aged 40-59 years at entry from a prospective population survey. During a mean follow-up time of 11 years, 234 coronary deaths occurred, 150 of which were sudden, i.e. ensuing within 1 hour of the onset of symptoms. The severity of the manifestations of CHD at baseline investigation appeared to be a powerful predictor of sudden coronary death. Smoking and high serum cholesterol were significant predictors of sudden coronary death. High serum cholesterol was an equally significant predictor of sudden and non-sudden coronary death. High blood pressure did not appear to significantly increase sudden coronary death but increased the incidence of non-sudden death significantly. Obesity and diabetes did not appear to be independent risk factors for sudden coronary death. Smoking and high serum cholesterol were significant risk factors for sudden coronary death in men with manifestations of coronary heart disease. The results suggest that reduction of primary risk factors, especially smoking and high serum cholesterol, is important even after coronary heart disease has become manifest.

Homocysteinemia, hypertension, and family history of diabetes in a smoking male population in Saudi Arabia

Arabs have a lower incidence of atherosclerosis than other ethnicities, but few studies have examined homocysteine (HCYS) as a risk factor for cardiovascular disease in this population. Here, we investigated the association between serum HYCS levels and risk factors for cardiovascular disease (smoking, hypertension, and family history of diabetes) in Saudi males. A total of 50 smokers and 72 nonsmokers completed a general health questionnaire. In addition, their lipid profiles were measured using routine methods and HCYS levels by high-performance liquid chromatograph with electrochemical detection. Regression analysis showed negative associations between HCYS and glucose (r = −0.22; P < 0.05) as well as family history of diabetes (r = −0.21; P < 0.05). HCYS levels were similar between hypertensive and nonhypertensive smokers, but they were significantly elevated in hypertensive nonsmokers (P = 0.027) and lower in smokers with family history of diabetes (P = 0.01). Levels of HCYS among nonsmokers inversely correlated with history of diabetes and elevated glucose. Nonsmokers’ HCYS levels were significantly elevated in the presence of hypertension and correlated with diastolic blood pressure. Thus, HCYS may be a predictor of hypertension among nonsmokers. Until further trials are conducted, we recommend vitamin B6/folic acid supplementation for the Saudi hypertensive population as an adjuvant therapy.

The value of gamma-glutamyltransferase in cardiovascular risk prediction in men without diagnosed cardiovascular disease or diabetes

AIMS

We have examined the relationship between gamma-glutamyltransferase (GGT) and major coronary heart disease (CHD) and stroke events and cardiovascular mortality in men free of cardiovascular disease (CVD).

METHODS

A prospective study of 6997 men aged 40-59 with no history of CVD (CHD or stroke) or diabetes drawn from general practices in 24 British towns and followed up for 24 years.

RESULTS

GGT was significantly and positively associated with increased risk of fatal (but not non-fatal CHD events), major stroke events and total CVD mortality after adjustment for established CVD risk factors. Risk of fatal CHD and CVD mortality was only elevated in the top quarter (22IU/L); risk of stroke tended to increase with increasing GGT. The adjusted relative risks (Q4 vs. Q1) were 1.43 (1.09,1.84) for fatal CHD events, 1.56 (1.20,2.04) for stroke incidence and 1.40 (1.16,1.70) for CVD mortality. When stratified by age groups stronger associations were seen between GGT and CVD mortality in the younger men (<55 years) (p=0.01 for interaction). GGT significantly predicted CVD outcomes especially in those at low and medium CHD risk based on Framingham risk score (FRS).

CONCLUSION

Elevated GGT is associated with significantly increased risk of stroke, fatal CHD events and CVD mortality independent of established CVD risk factors and may be a useful additional marker for long-term CVD risk.

Psychosocial interventions for smoking cessation in patients with coronary heart disease

BACKGROUND

Quitting smoking improves prognosis after a cardiac event, but many patients continue to smoke, and improved cessation aids are urgently required.

OBJECTIVES

To assess the effectiveness of psychosocial interventions such as behavioural therapeutic intervention, telephone support and self-help interventions in helping people with coronary heart disease (CHD) to quit smoking.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (issue 2 2003), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to August 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews.

SELECTION CRITERIA

Randomised controlled studies (RCTs) in patients with CHD with a minimum follow-up of 6 months. After initial selection of the studies three trials with methodological flaws (e.g. high drop out) were excluded.

DATA COLLECTION AND ANALYSIS

Abstinence rates were computed according to an intention to treat analysis if possible, or if not on follow-up results only.

MAIN RESULTS

We found 16 RCTs meeting inclusion criteria. Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors. The trials mostly included older male patients with CHD, predominantly myocardial infarction. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (odds ratio (OR) 1.66, 95% confidence interval (CI) 1.25 to 2.22), but substantial heterogeneity between trials. Studies with validated assessment of smoking status at follow-up had lower efficacy (OR 1.44, 95% CI 0.99 to 2.11) than non-validated trials (OR 1.92, 95% CI 1.26 to 2.93). Studies were clustered by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The ORs for different strategies were similar (behavioural therapies OR 1.69, 95% CI 1.33 to 2.14; telephone support OR 1.58, 95% CI 1.28 to 1.97; self-help OR 1.48, 95% CI 1.11 to 1.96). More intense interventions showed increased quit rates (OR 1.98, 95% CI 1.49 to 2.65) whereas brief interventions did not appear effective (OR 0.92, 95% CI 0.70 to 1.22). Two trials had longer term follow-up, and did not show any benefits after 5 years.

AUTHORS' CONCLUSIONS

Psychosocial smoking cessation interventions are effective in promoting abstinence at 1 year, provided they are of sufficient duration. Further studies, with longer follow-up, should compare different psychosocial intervention strategies, or the addition of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone.

Primary prevention of cardiovascular disease: a web-based risk score for seven British black and minority ethnic groups

OBJECTIVE

To recalibrate an existing Framingham risk score to produce a web-based tool for estimating the 10-year risk of coronary heart disease (CHD) and cardiovascular disease (CVD) in seven British black and minority ethnic groups.

DESIGN

Risk prediction models were recalibrated against survey data on ethnic group risk factors and disease prevalence compared with the general population. Ethnic- and sex-specific 10-year risks of CHD and CVD, at the means of the risk factors for each ethnic group, were calculated from the product of the incidence rate in the general population and the prevalence ratios for each ethnic group.

SETTING

Two community-based surveys.

PARTICIPANTS

3778 men and 4544 women, aged 35-54, from the Health Surveys for England 1998 and 1999 and the Wandsworth Heart and Stroke Study.

MAIN OUTCOME MEASURES

10-year risk of CHD and CVD.

RESULTS

10-year risk of CHD and CVD for non-smoking people aged 50 years with a systolic blood pressure of 130 mm Hg and a total cholesterol to high density lipoprotein cholesterol ratio of 4.2 was highest in men for those of Pakistani and Bangladeshi origin (CVD risk 12.6% and 12.8%, respectively). CHD risk in men with the same risk factor values was lowest in Caribbeans (2.8%) and CVD risk was lowest in Chinese (5.4%). Women of Pakistani origin were at highest risk and Chinese women at lowest risk for both outcomes with CVD risks of 6.6% and 1.2%, respectively. A web-based risk calculator (ETHRISK) allows 10-year risks to be estimated in routine primary care settings for relevant risk factor and ethnic group combinations.

CONCLUSIONS

In the absence of cohort studies in the UK that include significant numbers of black and minority ethnic groups, this risk score provides a pragmatic solution to including people from diverse ethnic backgrounds in the primary prevention of CVD.

Potential vascular benefits of statins

Atherosclerosis is associated with a number of functional abnormalities that affect endothelium-dependent vasomotor function, inflammation, and thrombosis. The 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) have effects on many of these functions, likely explaining their benefit in reducing the incidence of clinical events in patients at high risk of cardiovascular disease. Statins may improve this vascular biology by lowering levels of low-density lipoprotein (LDL) or potentially by a number of non-LDL-related mechanisms. Cell culture and some animal studies have demonstrated LDL-independent effects of statins. The non-LDL mechanisms include effects on isoprenoid production and function, interactions between caveolin and nitric oxide synthase, and direct immunomodulatory effects. Although these mechanisms are clearly demonstrated in the experimental setting, their relevance to the clinical use of statins is unknown. From a purely pragmatic viewpoint, the debate of lipid versus nonlipid effects of statins matters little to clinical practice. Their proven effect on vascular biology and risk reduction justifies their important therapeutic role.

Overweight and obesity and weight change in middle aged men: impact on cardiovascular disease and diabetes

CONTEXT

The benefit of weight reduction for cardiovascular disease (CVD) outcomes remains uncertain.

OBJECTIVE

To examine the effects of baseline body mass index on major CVD outcomes and diabetes over a 20 year follow up, and of weight change in the first five years over the subsequent 15 years.

DESIGN AND SETTING

A prospective study of British men followed up for 20 years.

PARTICIPANTS

Men aged 40-59 years with no diagnosis of CVD or diabetes (n = 7176) of whom 6798 provided full information on weight change five years later.

OUTCOME MEASURES

Major CVD events (fatal and non-fatal myocardial infarction and stroke, angina, "other" CVD deaths) and diabetes.

RESULTS

During the 20 year follow up there were 1989 major CVD events and 449 incident cases of diabetes in the 7176 men. Risk of major CVD and diabetes increased significantly with increasing overweight and obesity. During the 15 year follow up, weight gain was associated with increased risk of CVD and diabetes. Weight loss was associated with lower risk of diabetes than the stable group irrespective of initial weight. No significant cardiovascular benefit was seen for weight loss in any men, except possibly in considerably overweight (BMI 27.5-29.9 kg/m(2)) younger middle aged men (RR = 0.42; 95% CI 0.22 to 0.81).

CONCLUSION

Long term risk of CVD and diabetes increased significantly with increasing overweight and obesity. Weight loss was associated with significant reduction in risk of diabetes but not CVD, except possibly in considerably overweight younger men. Duration and severity of obesity seem to limit the cardiovascular benefits of weight reduction in older men.

The HDL2/HDL3 ratio in menopause

OBJECTIVES

The influence of the menopause on the HDL2/HDL3 ratio was assessed in association with hypertriglyceridemia.

METHODS

Fasting blood samples were collected from 607 patients. Commercially available enzymatic methods were used for determination of TG, and total HDL-C. HDL2 and HDL3 were measured by ultracentrifugation.

RESULTS

The HDL2/HDL3 ratio had a strong negative correlation with TG (r=-0.272, P<0.0001 and r=-0.314, P<0.0001) in both pre- and postmenopausal women. No significant differences were observed in HDL2, HDL3, and HDL2/HDL3 ratio between pre- and postmenopausal women without hypertriglyceridemia. Postmenopausal women had a significantly higher HDL2/HDL3 ratio than premenopausal women with hypertriglyceridemia.

CONCLUSIONS

These results indicate that menopausal status not only increases plasma LDL-cholesterol and triglyceride levels, but also increases the HDL2/HDL3 ratio when associated with elevation of plasma triglyceride levels. These changes may increase the risk for CHD due to enlargement of the lipid pool.

Social inequalities and disability in older men: prospective findings from the British regional heart study

The independent association of socio-economic position with self-reported disability was assessed. The effect of home and car ownership as additional indices of socio-economic position within occupational social classes was explored. Data from a prospective study of a cohort of 7735 men aged 40-59 years at recruitment and representative of the occupational social class distribution of middle-aged men in Great Britain were used. Men were selected from one general practice in each of 24 towns in England, Wales and Scotland in 1978-1980. The present study concerns 5773 (88.4% of those able to take part) men aged 52-73 years at follow up in 1992 who completed the disability section of a postal questionnaire. A quarter (1453) of men reported disability. Socio-economic position measured as both occupational class (social class I vs. V: age-adjusted OR 5.0, 95% CI 3.4-7.5) and ownership of home and car (both vs. neither: age-adjusted OR 2.8, 95% CI 2.3-3.4) showed a graded relationship with likelihood of reporting disability in 1992. Within all social class groups, those owning both home and car had a lower risk of disability than those who owned neither, even after adjustment for a wide range of risk factors. Men from manual occupations were more likely than those in non-manual occupations to report disability on developing chronic diseases. The relationship between socio-economic position and severe, but not milder, disability appeared to be independent of disease status. Socio-economic position is a strong predictor of disability in later life independent of a wide range of lifestyle factors and presence of diagnosed disease. The likelihood of reporting disability between and within social class groups is influenced by material wealth.

Serum albumin and risk of stroke, coronary heart disease, and mortality: the role of cigarette smoking

OBJECTIVE

Lower levels of serum albumin are associated with increased risk of all-cause and cardiovascular mortality as well as with coronary heart disease and stroke incidence. These relationships have been examined with specific focus on the role of cigarette smoking.

STUDY DESIGN AND SETTING

A prospective study of 7,690 British men aged 40-59 years, with 16.8 years mean follow-up.

RESULTS

Cigarette smoking was strongly and inversely associated with serum albumin concentrations that reverted to levels seen in never smokers after 5 years' cessation. Only in current and former smokers were there significant inverse relationships between serum albumin and risk of major CHD and stroke events even after adjustment for potential confounders. Only in current smokers was a significant inverse relationship seen between serum albumin and mortality from cardiovascular disease, cancer, and all causes.

CONCLUSION

The inverse association between serum albumin concentration and disease outcome appears to be related to the effects of cigarette smoking on serum albumin concentration.

Smoking cessation for the secondary prevention of coronary heart disease

BACKGROUND

Although the importance of smoking as a risk factor for coronary heart disease is beyond doubt, the speed and magnitude of risk reduction when a smoker with coronary heart disease quits are still subjects of debate.

OBJECTIVES

To estimate the magnitude of risk reduction when a patient with CHD stops smoking.

SEARCH STRATEGY

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index, CINAHL, PsychLit, Dissertation Abstracts, BIDS ISI Index to Scientific and Technical Proceedings, UK National Research Register from the start of each database. Sixty-one large international cohort studies of cardiovascular disease were identified, and contact made with authors to search for any unpublished results. The search was supplemented by cross-checking references and contact with various experts. Date of last search was April 2003.

SELECTION CRITERIA

Any prospective cohort studies of patients with a diagnosis of CHD, which include all-cause mortality as an outcome measure. Smoking status must be measured on at least two occasions to ascertain which smokers have quit, and followed-up for at least two years.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed independently by two reviewers.

MAIN RESULTS

Twenty studies were included. There was a 36% reduction in crude relative risk (RR) of mortality for those who quit smoking compared with those who continued to smoke (RR 0.64, 95% confidence interval 0.58 to 0.71). There was also a reduction in non-fatal myocardial infarctions (crude RR 0.68, 95% confidence interval 0.57 to 0.82). Many studies did not adequately address quality issues, such as control of confounding, and misclassification of smoking status. However, there was little difference in the results for the six 'higher quality' studies, and little heterogeneity between these studies. This review was not able to assess how quickly the risk of mortality was reduced.

REVIEWER'S CONCLUSIONS

Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD. The pooled crude RR was 0.64 (95% CI 0.58 to 0.71). This 36% risk reduction appears substantial compared with other secondary preventive therapies such as cholesterol lowering which have received greater attention in recent years. The risk reduction associated with quitting smoking seems consistent regardless of differences between the studies in terms of index cardiac events, age, sex, country, and time period. However, relatively few studies have included large numbers of older people, women, or people of non-European descent, and most were carried out in Western countries.

Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review

CONTEXT

As more interventions become available for the treatment of coronary heart disease (CHD), policy makers and health practitioners need to understand the benefits of each intervention, to better determine where to focus resources. This is particularly true when a patient with CHD quits smoking.

OBJECTIVE

To conduct a systematic review to determine the magnitude of risk reduction achieved by smoking cessation in patients with CHD.

DATA SOURCES

Nine electronic databases were searched from start of database to April 2003, supplemented by cross-checking references, contact with experts, and with large international cohort studies (identified by the Prospective Studies Collaboration).

STUDY SELECTION

Prospective cohort studies of patients who were diagnosed with CHD were included if they reported all-cause mortality and had at least 2 years of follow-up. Smoking status had to be measured after CHD diagnosis to ascertain quitting.

DATA EXTRACTION

Two reviewers independently assessed studies to determine eligibility, quality assessment of studies, and results, and independently carried out data extraction using a prepiloted, standardized form.

DATA SYNTHESIS

From the literature search, 665 publications were screened and 20 studies were included. Results showed a 36% reduction in crude relative risk (RR) of mortality for patients with CHD who quit compared with those who continued smoking (RR, 0.64; 95% confidence interval [CI], 0.58-0.71). Results from individual studies did not vary greatly despite many differences in patient characteristics, such as age, sex, type of CHD, and the years in which studies took place. Adjusted risk estimates did not differ substantially from crude estimates. Many studies did not adequately address quality issues, such as control of confounding, and misclassification of smoking status. However, restriction to 6 higher-quality studies had little effect on the estimate (RR, 0.71; 95% CI, 0.65-0.77). Few studies included large numbers of elderly persons, women, ethnic minorities, or patients from developing countries.

CONCLUSIONS

Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD. This risk reduction appears to be consistent regardless of age, sex, index cardiac event, country, and year of study commencement.

Epidemiology of smoking-induced cardiovascular disease

Cigarette smoking is a major cause of coronary heart disease, stroke, aortic aneurysm, and peripheral vascular disease. The risk is manifest both as an increased risk for thrombosis of narrowed vessels and as an increased degree of atherosclerosis in those vessels. The cardiovascular risks owing to cigarette smoking increase with the amount smoked and with the duration of smoking. Risks are not reduced by smoking cigarettes with lower machine-measured yields of tar and nicotine, but those who have only smoked pipes or cigars seem to have a lower risk for cardiovascular diseases. Cessation of cigarette smoking reduces disease risks, although risks may remain elevated for a decade or more after cessation.

Geographical variation in cardiovascular disease, risk factors, and their control in older women: British Women's Heart and Health Study

OBJECTIVES

To measure the geographical variation in prevalence of cardiovascular disease, risk factors, and their control in a nationally representative sample of older British women.

METHODS

Baseline survey using general practitioner record review, a self completed questionnaire, research nurse interview, and physical examination in a randomly selected sample of women aged 60-79 drawn from 23 towns in England, Scotland, and Wales.

RESULTS

Of 7,173 women invited and eligible to participate, information was obtained on 4,286 (60%). One in five women had a doctor diagnosis of any one of myocardial infarction, angina, heart failure, stroke, or peripheral vascular disease. Fifty per cent of women were hypertensive, 12% smoked, and over one quarter were obese. Fifty per cent had a total cholesterol level greater than 6.5 mmol/l, though only 3% had low high density lipoprotein concentrations. Cardiovascular disease prevalence varied by geographical region being highest in Scotland: age adjusted prevalence (95% confidence intervals) 25.0% (21.5% to 28.8%) and lowest in South England: age adjusted prevalence (95% confidence intervals) 15.4% (13.5% to 17.6%). The geographical variations in cardiovascular disease prevalence were attenuated by adjustment for risk factors and socioeconomic position; further adjustment for health service use (as indicated by aspirin or statin use) reduced the differences further. However, variation remained even after full adjustment for these factors: odds ratio (95% confidence intervals) comparing Midlands and Wales to South England 1.15 (0.82 to 1.61) and comparing Scotland to South England 1.53 (1.08 to 2.14). Of women with cardiovascular disease, 12% were current smokers, a third had uncontrolled hypertension, a third were obese, and 90% had a blood cholesterol over 5 mmol/l. Only 41% were taking antiplatelet drugs and 22% were taking a statin.

CONCLUSIONS

Older British women have a higher prevalence of cardiovascular disease and risk factors than previously documented. The workload consequences of attempting to control risk factors and ensure optimal secondary prevention for older British women are considerable. Geographical variations in cardiovascular disease prevalence in older women are somewhat, but not fully, explained by variations in major risk factors, socioeconomic position, and health service utilisation.

Smoking cessation for the secondary prevention of coronary heart disease

BACKGROUND

Although the importance of smoking as a risk factor for coronary heart disease is beyond doubt, the speed and magnitude of risk reduction when a smoker with coronary heart disease quits are still subjects of debate.

OBJECTIVES

To estimate the magnitude of risk reduction when a patient with CHD stops smoking.

SEARCH STRATEGY

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index, CINAHL, PsychLit, Dissertation Abstracts, BIDS ISI Index to Scientific and Technical Proceedings, UK National Research Register from the start of each database. Sixty-one large international cohort studies of cardiovascular disease were identified, and contact made with authors to search for any unpublished results. The search was supplemented by cross-checking references and contact with various experts. Date of last search was April 2003.

SELECTION CRITERIA

Any prospective cohort studies of patients with a diagnosis of CHD, which include all-cause mortality as an outcome measure. Smoking status must be measured on at least two occasions to ascertain which smokers have quit, and followed-up for at least two years.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed independently by two reviewers.

MAIN RESULTS

Twenty studies were included. There was a 36% reduction in crude relative risk (RR) of mortality for those who quit smoking compared with those who continued to smoke (RR 0.64, 95% confidence interval 0.58 to 0.71). There was also a reduction in non-fatal myocardial infarctions (crude RR 0.68, 95% confidence interval 0.57 to 0.82). Many studies did not adequately address quality issues, such as control of confounding, and misclassification of smoking status. However, there was little difference in the results for the six 'higher quality' studies, and little heterogeneity between these studies. This review was not able to assess how quickly the risk of mortality was reduced.

REVIEWER'S CONCLUSIONS

Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD. The pooled crude RR was 0.64 (95% CI 0.58 to 0.71). This 36% risk reduction appears substantial compared with other secondary preventive therapies such as cholesterol lowering which have received greater attention in recent years. The risk reduction associated with quitting smoking seems consistent regardless of differences between the studies in terms of index cardiac events, age, sex, country, and time period. However, relatively few studies have included large numbers of older people, women, or people of non-European descent, and most were carried out in Western countries.

The development of a simulation model of primary prevention strategies for coronary heart disease

This paper describes the present state of development of a discrete-event micro-simulation model for coronary heart disease prevention. The model is intended to support health policy makers in assessing the impacts on health care resources of different primary prevention strategies. For each person, a set of times to disease events, conditional on the individual's risk factor profile, is sampled from a set of probability distributions that are derived from a new analysis of the Framingham cohort study on coronary heart disease. Methods used to model changes in behavioural and physiological risk factors are discussed and a description of the simulation logic is given. The model incorporates POST (Patient Oriented Simulation Technique) simulation routines.

Are we negating the benefits of CABG by forgetting secondary prevention?

The objective of the study was to examine medically managed secondary prevention at one year after coronary artery bypass grafting (CABG). In all, 214 consecutive patients undergoing isolated elective CABG seen four weeks preoperatively and one year post-operatively. Preoperative systolic blood pressure averaged 135+/-20 mmHg, which increased to 148+/-25 mmHg (P<0.0001) as did diastolic pressure (81+/-12 to 87+/-13 mmHg; P<0.0001). Anginal symptoms were reported by 45.1% (P<0.0001) although median severity scored lower (4.0 [3.0-5.4] vs 0 [0-2.0]; P<0.0001). Breathlessness decreased from 93% to 64% (P<0.0001) and was scored less severely (4.0 [2.0-5.0] vs 2.0 [0-4.0]; P<0.0001. In all, 88% with postoperative angina reported dyspnoea against 44% of those without (P<0.0001). Calcium antagonist use was more common in patients with angina (27.2% vs 5.1%; P<0.0001), but not nitrates (P=0.8695), diuretics (P=0.4218), digoxin (P=0.2565), beta-blockers (P=0.0820), or ACE inhibitors (P=0.7256). Preoperatively 166 patients (80.2%) took aspirin vs 69.2% afterwards (P=0.0131). Twelve patients (6.5%) received warfarin after operation vs none preoperatively. Two took digoxin (0.97%) preoperatively and 14 (7.7%) postoperatively (P=0.001) for chronic atrial fibrillation. One of these took warfarin. Long-acting nitrate use fell from 63.4% to 15.8% (P <0.0001). Short-acting nitrate use fell similarly (P<0.0001). Preoperatively 37 patients (17.9%) took ACE inhibitors vs 44 postoperatively (24.2%); 39 had not received them before. Preoperatively 48 (23.2%) took diuretics vs 30 (16.5%) postoperatively (P=0.127); 24 had not previously taken diuretics. More patients took HMGCoA inhibitors postoperatively (P=0.0068) and total cholesterol was significantly reduced with a concomitant increase in HDL fraction. Smoking habit was virtually unchanged from 17.8% to 15.1% (P=0.5023).

IN CONCLUSION

angina was common. Apart from statin prescribing, postoperative secondary prevention measures were poorly applied, less widespread and less effective than preoperatively. The implications are disturbing.

Improvements in total mortality and lipid levels after acute myocardial infarction in an English health district (1995-1999)

OBJECTIVES

To quantify changes in 30 day and one year mortality among patients with acute myocardial infarction in southern Derbyshire (population 560 000) in each of five consecutive years (1995-1999) before the publication of the National Service Framework for coronary heart disease, and to assess the proportion of one year survivors in whom serum lipids were measured and were below target values.

DESIGN

All hospital admissions coded on the patient administration system (PAS) as "AMI" (ICD codes I-21, I-22, and I-23) and with a creatine kinase measurement in the pathology database were identified over a five year period (n = 4912). All deaths in the district are automatically notified to the PAS. Total mortality after acute myocardial infarction (30 days and one year) and lipid levels were analysed by year of admission, age group (35-74 years v > or = 75 years), and sex using unconditional logistic regression analysis.

SETTING

An acute hospitals trust and pathology laboratory, as sole service providers for a catchment population of 560 000.

RESULTS

The number of admissions for acute myocardial infarction was similar in each of the five years (n = 4912, 62% male, 63% < 75 years old). Overall, among patients aged 35-74 years there were 396 deaths (13%) at 30 days and 585 (19%) at one year; mortality was higher in women (1.28-fold at 30 days, p = 0.02) and in subjects aged 75 years or more (3.26-fold at 30 days, p < 0.0001). There was a progressive reduction in 30 day mortality of 9%/year over the five year period (95% confidence interval, 4% to 13%, p = 0.012). The proportion of one year survivors (35-74 years) in whom serum lipids were measured at least once increased from 74% in 1995 to 88% in 1999; of these, 27% of men and 23% of women had a total serum cholesterol of < 5 mmol/l in 1995, increasing to 65% and 74%, respectively, in 1998 and 1999 (p < 0.0001).

CONCLUSIONS

In the five year period 1995-1999, there was a significant year on year decline in 30 day and one year mortality after admission for acute myocardial infarction, and progressively more patients achieved cholesterol levels below 5 mmol/l. Men were more likely than women to have their lipids measured after myocardial infarction. Mortality at one year was 1.32-fold higher among women than among men.

Life expectancy determination

The estimate of life expectancy following a personal injury is probably one of the most important factors in determining the final quantum of damages. It is a calculation fraught with difficulties. This article endeavours to outline some general factors that aid prediction of life expectancy, and also discusses the evidence from the few long-term studies currently available.

A comparative evaluation of waist circumference, waist-to-hip ratio and body mass index as indicators of cardiovascular risk factors. The Canadian Heart Health Surveys

OBJECTIVE

To comparatively evaluate cut-off points of waist circumference, body mass index and waist to hip ratio with respect to their ability to predict other individual and multiple cardiovascular disease risk factors.

DESIGN

Population-based, cross-sectional surveys.

SUBJECTS

A total of 9913 men and women aged 18-74, selected using health insurance registries from five Canadian provinces.

MEASUREMENTS

Anthropometric measures, other cardiovascular risk factors, receiver operating characteristic curves, sensitivity, specificity, positive and negative predictive values.

RESULTS

: Waist circumference may be the best single indicator of other individual and multiple cardiovascular risk factors. Optimal cut-off points of all anthropometric measures are dependent on age, sex and the prevalence of the risk factor(s) being considered. For waist circumference, cut-off points of > or =90 cm in men and > or =80 cm in women may be most appropriate for prediction of individual and multiple risk factors in Caucasian populations.

CONCLUSION

Health professionals should incorporate the use of waist circumference measurements in their routine clinical examination of adult patients.

Central obesity: predictive value of skinfold measurements for subsequent ischaemic heart disease at 14 years follow-up in the Caerphilly Study

OBJECTIVE

To assess the predictive value of central obesity for risk of ischaemic heart disease (IHD) in a long-term follow-up, measured by skinfold thickness in comparison to general measures of overweight and obesity such as Quetelet's index.

SUBJECTS AND DESIGN

A total of 2512 men aged 45-59 y from the general population first examined in 1979-1982. Men were re-examined at approximately 5 y intervals. All fatal and non-fatal cases of IHD during a 14 y follow-up were recorded.

MEASUREMENTS

Skinfold thickness was measured at four sites. Height (m) and weight (kg) were also measured and Quetelet's index (weight/height(2)) was used as the reference body mass index (BMI).

RESULTS

Data were available for 2512 men among whom 411 new cases of IHD (fatal and non-fatal) occurred during 14 y of follow-up. Increasing values of BMI showed a statistically significant trend with increasing risk of new IHD that contributed independently to risk of IHD when adjusted for age, smoking habit and social class. Skinfold thickness measures were entered singly and in combination into this model with and without the additional inclusion of BMI. All individual skinfolds were significantly associated with risk of new IHD when BMI was excluded from the regression model, as was the sum of four skinfolds and the sum of subscapular and abdominal skinfolds. Only the subscapular skinfold measure contributed independently to risk of subsequent IHD when BMI was included in the model although biceps, biceps plus triceps and total sum of skinfolds were close to achieving statistical significance. The relative odds of IHD in the upper quintile of subscapular skinfold compared to the lowest was 1.9 (95% CI 1.3-2.8) when adjusted for age, smoking habit and social class.

CONCLUSIONS

In general skinfold measurements contribute only marginally to improved prediction of risk of IHD as measured by BMI, but central obesity, as measured by the subscapular skinfold, is predictive of IHD independently of BMI.

Nurse led shared care for patients on the waiting list for coronary artery bypass surgery: a randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a nurse led shared care programme to improve coronary heart disease risk factor levels and general health status and to reduce anxiety and depression in patients awaiting coronary artery bypass grafting (CABG).

DESIGN

Randomised controlled trial.

SETTING

Community, January 1997 to March 1998.

STUDY GROUPS

98 (75 male) consecutive patients were recruited to the study within one month of joining the waiting list for elective CABG at Glasgow Royal Infirmary University NHS Trust. Patients were randomly assigned to usual care (control; n = 49) or a nurse led intervention programme (n = 49).

INTERVENTION

A shared care programme consisting of health education and motivational interviews, according to individual need, was carried out monthly. Care was provided in the patients' own homes by the community based cardiac liaison nurse alternating with the general practice nurse at the practice clinic.

OUTCOME MEASURES

Smoking status, obesity, physical activity, anxiety and depression, general health status, and proportion of patients exceeding target values for blood pressure, plasma cholesterol, and alcohol intake.

RESULTS

Compared with patients who received usual care, those participating in the nurse led programme were more likely to stop smoking (25% v 2%, p = 0.001) and to reduce obesity (body mass index > 30 kg/m(2)) (16.3% v 8.1%, p = 0.01). Target systolic blood pressure improved by 19.8% compared with a 10.7% decrease in the control group (p = 0.001) and target diastolic blood pressure improved by 21.5% compared with 10.2% in the control group (p = 0.000). However, there was no significant difference between groups in the proportion of patients with cholesterol concentrations exceeding target values. There was a significant improvement in general health status scores across all eight domains of the 36 item short form health survey with changes in difference in mean scores between the groups ranging from 8.1 (p = 0.005) to 36.1 (p < 0.000). Levels of anxiety and depression improved (p < 0.000) and there was improvement in time spent being physically active (p < 0.000).

CONCLUSIONS

This nurse led shared care intervention was shown to be effective for improving care for patients on the waiting list for CABG.

The socioeconomic position of employed women, risk factors and mortality

Many studies have demonstrated the graded association between socioeconomic position and health. Few of these studies have examined the cumulative effect of socioeconomic position throughout the lifecourse, and even fewer have included women. Those that have explored gender differences affirm the importance of studying the factors that predict women and men's health separately. This study addresses the associations between cross-sectional and longitudinal socioeconomic position, risk factors for cardiovascular disease and mortality from various causes. Analyses are based on data from a cohort of working Scottish women recruited between 1970 and 1973. Five socioeconomic measures were explored in relation to diastolic blood pressure, plasma cholesterol concentration, body mass index, forced expiratory volume in 1 s (FEV1). amount of recreational exercise taken, cigarette smoking and alcohol consumption. In general, for each of the five measures of socioeconomic position, there were significant differences in at least one of the age-adjusted physiological risk factors for cardiovascular disease (diastolic blood pressure, plasma cholesterol concentration, body mass index, FEV1). There were also significant differences in the percentage of current cigarette smokers according to different measures of socioeconomic position, although this was not the case for the other behavioural risk factors for cardiovascular disease (amount of recreational exercise taken, and alcohol consumption). Measures of socioeconomic position were also examined in relation to cause of death for the women who died before 1 January 1999. After adjusting for age and risk factors, a composite measure of lifetime socioeconomic experience was a more potent predictor of all cause mortality and mortality from cardiovascular disease than other measures of socioeconomic position. It therefore seems that conventional measurcs of socioeconomic position, estimated at one point in time, do not adequately capture the effects of socioeconomic circumstances on the risk of mortality among employed women. Thus, a broader range of explanatory factors for mortality differentials than currently exists must be considered, and must include consideration of factors operating throughout the lifecourse.

Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care

OBJECTIVE

To assess the effectiveness of three different methods of promoting secondary prevention of coronary heart disease in primary care.

DESIGN

Pragmatic, unblinded, cluster randomised controlled trial.

SETTING

Warwickshire.

SUBJECTS

21 general practices received intervention; outcome measured in 1906 patients aged 55-75 years with established coronary heart disease.

INTERVENTIONS

Audit of notes with summary feedback to primary health care team (audit group); assistance with setting up a disease register and systematic recall of patients to general practitioner (GP recall group); assistance with setting up a disease register and systematic recall of patients to a nurse led clinic (nurse recall group).

MAIN OUTCOME MEASURES

At 18 months' follow up: adequate assessment (defined) of 3 risk factors (blood pressure, cholesterol, and smoking status); prescribing of hypotensive agents, lipid lowering drugs, and antiplatelet drugs; blood pressure, serum cholesterol level, and plasma cotinine levels.

RESULTS

Adequate assessment of all 3 risk factors was much more common in the nurse and GP recall groups (85%, 76%) than the audit group (52%). The advantage in the nurse recall compared with the audit group was 33% (95% confidence interval 19% to 46%); in the GP recall group compared with the audit group 23% (10% to 36%), and in the nurse recall group compared with the GP recall group 9% (-3% to 22%). However, these differences in assessment were not reflected in clinical outcomes. Mean blood pressure (148/80, 147/81, 148/81 mm Hg), total cholesterol (5.4, 5.5, 5.5 mmol/l), and cotinine levels (% probable smokers 17%, 16%, 19%) varied little between the nurse recall, GP recall, and audit groups respectively, as did prescribing of hypotensive and lipid lowering agents. Prescribing of antiplatelet drugs was higher in the nurse recall group (85%) than the GP recall or audit groups (80%, 74%). After adjustment for baseline levels, the advantage in the nurse recall group compared with the audit group was 10% (3% to 17%), in the nurse recall group compared with the GP recall group 8% (1% to 15%) and in the GP recall group compared with the audit group 2% (-6% to 10%).

CONCLUSIONS

Setting up a register and recall system improved patient assessment at 18 months' follow up but was not consistently better than audit alone in improving treatment or risk factor levels. Understanding the reasons for this is the key next step in improving the quality of care of patients with coronary heart disease.

Patients' responses to risk information about the benefits of treating hypertension

BACKGROUND

The medical profession is often presented with information on the value of treatment in terms of likely risk reduction. If this same information was presented to patients--so enabling them to give proper informed consent--would this affect their decision to be treated?

AIM

To examine patients' choice about treatment in response to different forms of risk presentation.

DESIGN OF STUDY

Postal questionnaire study.

SETTING

The questionnaire was sent to 102 hypertensive patients and 207 matched non-hypertensive patients aged between 35 and 65 years in a UK general practice.

METHODS

Patients were asked the likelihood, on a four-point scale, of their accepting treatment for a chronic condition (mild hypertension) on the basis of relative risk reduction, absolute risk reduction, number needed to treat, and personal probability of benefit.

RESULTS

An 89% response rate was obtained. Of these, 92% would accept treatment using a relative risk reduction model, 75% would accept treatment using an absolute risk reduction model, 68% would accept treatment using a number needed to treat model, and 44% would accept treatment with a personal probability of benefit model.

CONCLUSION

Many patients may prefer not to take treatment for mild hypertension if the risks were fully explained. However, given that the form of the explanation has a strong influence on the patient's decision, it is not clear how decision-making can be fully shared nor what should constitute informed consent to treatment in this situation.

Hospital admissions among male drivers in Denmark

OBJECTIVES

To facilitate decisions about interventions and to establish baseline values for future evaluation of preventive efforts, the aim of the present study was to elucidate the disease pattern among male professional drivers in Denmark. The study differentiated between drivers of goods vehicles and drivers of passenger transport.

METHODS

Cohorts of all 20-59 year old Danish male professional drivers in the years 1981, 1986, 1991, and 1994 were formed, to calculate age standardised hospital admission ratios (SHRs) and time trends (1981-97) for many diagnostic aggregations.

RESULTS

SHRs for diseases in practically all systems and organs of the body were higher among professional drivers than they were in the male working population at large. Also drivers of passenger transport, compared with drivers of goods vehicles, had significantly high SHRs due to infectious and parasitic diseases, diseases of the circulatory system, and diseases of the respiratory system, and significantly lower rates of injury. For both driver groups, the SHRs for acute myocardial infarction increased with time whereas the SHR for acute gastritis decreased, and for drivers of passenger transport an increasing SHR for chronic obstructive pulmonary disease, was found over time.

CONCLUSION

Drivers of passenger transport and drivers of goods vehicles differ in their disease patterns. The results support the hypothesis that preventive efforts are needed in both groups, but underline that different strategies are required for different categories of drivers.

Beneficial effects of pravastatin in peri- and postmenopausal hyperlipidemic women: a 5-year study on serum lipid and sex hormone levels

OBJECTIVES

The aims of the present study are to assess the 5 year effects of pravastatin on serum lipids and lipoproteins in women around the menopause and to assess the effects of pravastatin on serum gonadotropins and sex steroid levels over a long-term period.

METHODS

We evaluated the long-term efficacy of pravastatin on serum lipid levels (total cholesterol, LDL-cholesterol, HDL-cholesterol, triglyceride) in 121 patients (47 premenopausal and 74 postmenopausal women) suffering from primary hypercholesterolemia. The effects of this lipid-lowering drug on serum gonadotropins and sex steroids (estradiol, estrone, and testosterone) are also reported.

RESULTS

Pravastatin produced a remarkable reduction in the serum total cholesterol level of 19.2+/-9.3% (P<0.0001) and 18.9+/-11.8% (P<0.0001), and in LDLl-cholesterol of 25.1+/-18.7% (P<0.0001) and 24+/-18.0% (P<0.0001) after 24 and 60 months' treatment, respectively. In hypertriglyceridemia, pravastatin also produced a remarkable reduction in triglyceride of 29.3+/-27.3% (P<0.0001) and 39.9+/-20.4% (P<0.0001) after 24 and 60 months of treatment, respectively. We found that serum gonadotropins and sex steroid levels changed naturally as a function of age from pre-therapy levels in the premenopausal patients after 60 months of treatment.

CONCLUSIONS

Pravastatin was well tolerated over 5 years and was a very effective lipid-lowering agent for both hypercholesterolemia and hypertriglyceridemia with no effect on the biosynthesis of sex steroids. These findings suggest that pravastatin can be used in the treatment of hypercholesterolemia with/without high triglyceride levels in women around the menopause.

Lipoprotein (a) as a predictor of myocardial infarction in middle-aged men

PURPOSE

Whether serum lipoprotein (a) [Lp(a)] levels are an independent risk factor for coronary heart disease has been controversial. We have investigated its status in a prospective population survey, the Second Northwick Park Heart Study.

METHODS

We recruited 2,616 men 50 to 61 years old from nine primary care practices in the United Kingdom. Baseline serum Lp(a) levels were measured by enzyme-linked immunosorbent assay (ELISA) and were analyzed in 3 groups (<25th percentile, 25th to 75th percentile, and >75th percentile) to overcome the problem of some measurements falling below the threshold of the assay. Coronary end points included sudden cardiac death, acute myocardial infarction, silent myocardial infarction on the electrocardiogram, and coronary artery bypass surgery.

RESULTS

During a mean of 6 years of follow-up, 121 men had coronary events. In a multivariate analysis that also adjusted for fibrinogen, Apo-A1, Apo-B, and triglyceride levels, we identified several independent risk factors for coronary events, including cholesterol level (hazard ratio [HR] = 1.5 per SD 95% confidence interval [CI] 1.3 to 1.8), diabetes (HR = 4.1, 95% CI: 2. 0 to 8.4), current versus never smoking (HR = 2.5, 95% CI: 1.5 to 4.1), diastolic blood pressure (HR = 1.4 per SD, 95% CI: 1.1 to 1.7), Apo-A1 (HR = 0.8 per SD, 95% CI: 0.6 to 0.9), age (HR = 1.3 per SD, 95% CI: 1.1 to 1.6), and Lp(a) (>26.3 mg/dL [75th percentile] versus <2.9 mg/dL [25th percentile], HR = 1.9, 95% CI: 1.1 to 3.3]. There was a statistically significant (P = 0.01) difference in risk between the three levels of Lp(a).

CONCLUSIONS

We found that a high Lp(a) level was an independent predictor of the development of coronary heart disease in middle-aged men.

An assessment of morbidity registers for coronary heart disease in primary care. ASSIST (ASSessment of Implementation STrategy) trial collaborative group

BACKGROUND

Organised care delivered systematically to all patients with established coronary heart disease (CHD) can reduce their risk factors and improve their quality of life. Therefore, identifying all patients with established CHD in a general practice population is an important first step for delivering this effective healthcare. However, there is little information on how registers are compiled, the factors that predict inclusion on the register or the relationship between registration and level of care provided.

AIM

To assess the completeness of morbidity registers for CHD in primary care, the factors that predict inclusion on the register, and the relationship between registration and level of care provided.

METHOD

Observational study at baseline of 1979 patients aged 55 to 75 years with established CHD in 18 general practices recruited for a cluster randomised controlled trial.

RESULTS

The proportion of CHD patients correctly identified on practice morbidity registers varied from 29.3% to 100%. Four factors were significantly and independently associated with being on a register: a relevant surgery contact since diagnosis (OR = 2.1, 95% CI = 1.6%-2.9%); a relevant repeat prescription since diagnosis (OR = 1.6, 95% CI = 1.1%-2.3%); a diagnosis of myocardial infarction (OR = 1.5, 95% CI = 1.2%-1.9%); and a revascularisation procedure (OR = 1.5, 95% CI = 1.1%-2.0%). Inclusion on a register was strongly associated with being adequately assessed (i.e. assessed for smoking status, blood pressure, and cholesterol) (OR = 1.8, 95% CI = 1.3%-2.3%) and with treatment with aspirin or a lipid-lowering agent (OR = 1.4 for each agent).

CONCLUSION

A wide variation in registration levels between practices exists. There is evidence that practices using multiple methods of case detection achieve higher levels of registration. The association between registration and better care does not prove causality but an effective call-recall system is impossible without complete registration.

Erythrocyte lipid peroxidation and antioxidants in cigarette smokers

The present study has analysed the relationship between lipid peroxidation and antioxidant status in erythrocytes from 30 adult male cigarette smokers and an equal number of age and sex-matched normal subjects. Erythrocyte lipid peroxidation was markedly increased. The enzymic antioxidants were decreased in erythrocytes of cigarette smokers. The present study highlights the occurrence of lipid peroxidation and possible breakdown of antioxidant status in cigarette smoking.