Chest pain and coronary heart disease mortality among older men and women in three communities

Chest Symptoms and Long-Term Risk of Incident Cardiovascular Disease

BACKGROUND

We sought to evaluate the associations of chest pain and dyspnea with the long-term risk of cardiovascular disease including coronary disease, heart failure, atrial fibrillation, and stroke.

METHODS

In 13,200 participants without cardiovascular disease in the Atherosclerosis Risk in Communities study (1987-1989), chest pain was categorized into definite angina, possible angina, non-anginal chest pain, and no chest pain using the Rose questionnaire. Dyspnea was categorized into grades 3-4, 2, 1, and 0 by the modified Medical Research Council scale. The associations of chest pain and dyspnea with incident myocardial infarction, heart failure, atrial fibrillation, and stroke over a median follow-up of ∼27 years were quantified with multivariable Cox models.

RESULTS

Definite angina and possible angina were associated with myocardial infarction (adjusted hazard ratios [HR] 1.80 [95%CI 1.45-2.13] and 1.65 [1.27-2.15]). Although lesser magnitude than myocardial infarction, both definite and possible angina were associated with heart failure. For atrial fibrillation, possible angina showed higher HR than definite angina. Dyspnea showed similar HRs for myocardial infarction and heart failure in grades 3-4 (2.00 [1.61-2.49] and 1.94 [1.62-2.32]). Stroke was least associated with chest symptoms. Chest pain and dyspnea significantly improved the discrimination of cardiovascular disease except stroke, beyond traditional risk factors.

CONCLUSIONS

In individuals without cardiovascular disease, chest pain and dyspnea were independently associated with incident cardiovascular disease for about 3 decades, suggesting the need for evaluating chest pain from a broader perspective of cardiovascular disease beyond coronary disease and the importance of dyspnea for cardiovascular risk assessment including myocardial infarction.

Prevalence and factors associated with undiagnosed and uncontrolled heart disease: A study based on self-reported chronic heart disease and symptom-based angina pectoris among middle-aged and older Indian adults

BACKGROUND

This study aimed to examine the prevalence of heart diseases and angina pectoris and associated factors among middle-aged and older Indian adults. Additionally, the study examined the prevalence and associated factors of undiagnosed and uncontrolled heart disease among middle-aged and older adults based on self-reported chronic heart disease (CHD) and symptom-based angina pectoris (AP).

METHODS

We used cross-sectional data from the first wave of the Longitudinal Ageing Study of India, 2017-18. The sample consists of 59,854 individuals (27, 769 males and 32,085 females) aged 45 years and above. Maximum likelihood binary logistic regression models were employed to examine the associations between morbidities, other covariates (demographic factors, socio-economic factors and behavioral factors) and heart disease and angina.

RESULTS

A proportion of 4.16% older males and 3.55% older females reported the diagnosis of heart diseases. A proportion of 4.69% older males and 7.02% older females had symptom-based angina. The odds of having heart disease were higher among those who were hypertensive and who had family history of heart disease, and it was higher among those whose cholesterol levels were higher. Individuals with hypertension, diabetes, high cholesterol and family history of heart disease were more likely to have angina than their healthy counterparts. The odds of undiagnosed heart disease were lower but the odds of uncontrolled heart disease were higher among those who were hypertensive than non-hypertensive individuals. Those having diabetes were less likely to have undiagnosed heart disease while among the diabetic people the odds of uncontrolled heart disease were higher. Similarly, higher odds were observed among people with high cholesterol, having stroke and also among those who had a history of heart disease than their counterparts.

CONCLUSIONS

The present study provided a comparative prevalence of heart disease and agina and their associations with chronic diseases among middle-aged and older adults in India. The higher prevalence of undiagnosed and uncontrolled heart disease and their risk factors among middle-aged and older Indians manisfest alarming public health concerns and future health demand.

Sex Difference in the Risk of Dementia in Patients with Atrial Fibrillation

Atrial fibrillation (AF) is one of the risk factors for dementia. Female sex is an inconsistent risk factor for dementia after adjusting for age in the general population, and there lacks research on its impact in developing dementia in patients with AF. This paper aims to investigate whether female sex is a risk factor for dementia in AF patients. Data of patients with newly diagnosed AF between 2001–2013 were retrieved from Taiwan’s National Health Insurance Research Database. Exclusion criteria were: patients with incomplete demographic data, age < 20 years, rheumatic heart disease, hyperthyroidism, past valvular heart surgery, and a history of dementia. Propensity score matching (PSM) between sexes was performed, including comorbidities, medications and index date stratified by age. The primary outcome was a new diagnosis of dementia at follow-up. A total of 117,517 men and 156,705 women were eligible for analysis. After 1:1 PSM, both 100,065 men and women (aged 72.5 ± 12.5 years) were included for analysis. Dementia risk varied with age in women compared with men. The difference was negligible for ≤55 years (sub distribution HR (SHR) = 0.89, 95% CI 0.73–1.07), but increased between 56–65 years (SHR = 1.13, 95% CI 1.02–1.25), 66–75 years (SHR = 1.14, 95% CI 1.09–1.20), 75–85 years (SHR = 1.11, 95% CI 1.07–1.15) and >85 years (SHR 1.10, 95% CI 1.04–1.16) for females. This study establishes that female sex increases the risk of developing dementia compared to male sex in AF patients aged >56 years. However, the impact of female sex on dementia in AF patients differs between dementia types.

Chest pain, depression and anxiety in coronary heart disease: Consequence or cause? A prospective clinical study in primary care

OBJECTIVE

To examine if chest pain increases the risk of depression and anxiety, or, on the other hand, depression and anxiety increase the risk of chest pain onset in patients with coronary heart disease (CHD).

DESIGN

Prospective clinical study.

SETTING

16 general practices in the Greater London Primary Care Research Network.

PARTICIPANTS

803 participants with a confirmed diagnosis of CHD at baseline on the Quality and Outcomes Framework (QOF) CHD registers.

MAIN OUTCOME MEASURES

Rose Angina Questionnaire, HADS depression and anxiety subscales and PHQ-9 were assessed at seven time points, each 6 months apart. Multi-Level Analysis (MLA) and Structural Equation Modelling (SEM) were applied.

RESULTS

Chest pain predicts both more severe anxiety and depression symptoms at all time points until 30 months after baseline. However, although anxiety predicted chest pain in the short term with a strong association, this association did not last after 18 months. Depression had only a small, negative association with chest pain.

CONCLUSIONS

In persons with CHD, chest pain increases the risk of both anxiety and depression to a great extent. However, anxiety and depression have only limited effects on the risk for chest pain. This evidence suggests that anxiety and depression tend to be consequences rather than causes of cardiac chest pain. Intervention studies that support persons with CHD by providing this information should be devised and evaluated, thus deconstructing potentially catastrophic cognitions and strengthening emotional coping.

Epidemiology of coronary heart disease and acute coronary syndrome

The aim of this review is to summarize the incidence, prevalence, trend in mortality, and general prognosis of coronary heart disease (CHD) and a related condition, acute coronary syndrome (ACS). Although CHD mortality has gradually declined over the last decades in western countries, this condition still causes about one-third of all deaths in people older than 35 years. This evidence, along with the fact that mortality from CHD is expected to continue increasing in developing countries, illustrates the need for implementing effective primary prevention approaches worldwide and identifying risk groups and areas for possible improvement.

Determinants of premature mortality in a city population: an eight-year observational study concerning subjects aged 18-64

BACKGROUND

Premature deaths constitute 31.1% of all deaths in Łódź. Analysis of the causes of premature deaths may be helpful in the evaluation of health risk factors. Moreover, findings of this study may enhance prophylactic measures.

MATERIAL AND METHODS

In 2001, 1857 randomly selected citizens, aged 18-64, were included in the Countrywide Integrated Noncommunicable Diseases Intervention (CINDI) Programme. In 2009, a follow-up study was conducted and information on the subjects of the study was collected concerning their health status and if they continued to live in Łódź. The Cox proportional hazards model was used for evaluation of hazard coefficients. We adjusted our calculations for age and sex. The analysis revealed statistically significant associations between the number of premature deaths of the citizens of Łódź and the following variables: a negative self-evaluation of health - HR = 3.096 (95% CI: 1.729-5.543), poor financial situation - HR = 2.811 (95% CI: 1.183-6.672), occurring in the year preceding the study: coronary pain - HR = 2.754 (95% CI: 1.167-6.494), depression - HR = 2.001 (95% CI: 1.222-3.277) and insomnia - HR = 1.660 (95% CI: 1.029-2.678). Our research study also found a negative influence of smoking on the health status - HR = 2.782 (95% CI: 1.581-4.891). Moreover, we conducted survival analyses according to sex and age with Kaplan-Meier curves.

CONCLUSIONS

The risk factors leading to premature deaths were found to be highly significant but possible to reduce by modifying lifestyle-related health behaviours. The confirmed determinants of premature mortality indicate a need to spread and intensify prophylactic activities in Poland, which is a post-communist country, in particular, in the field of cardiovascular diseases.

Mortality implications of angina and blood pressure in hypertensive patients with coronary artery disease: New data from extended follow-up of the International Verapamil/Trandolapril Study (INVEST)

BACKGROUND

Angina and hypertension are common in patients with coronary artery disease (CAD); however, the effect on mortality is unclear. We conducted this prespecified analysis of the International Verapamil/Trandolapril Study (INVEST) to assess relationships between angina, blood pressure (BP), and mortality among elderly, hypertensive CAD patients.

HYPOTHESIS

Angina and elevated BP will be associated with higher mortality.

METHODS

Extended follow-up was performed using the National Death Index for INVEST patients in the United States (n = 16 951). Based on angina history at enrollment and during follow-up visits, patients were divided into groups: persistent angina (n = 7184), new-onset angina (n = 899), resolved angina (n = 4070), and never angina (n = 4798). Blood pressure was evaluated at baseline, during drug titration, and during follow-up on-treatment. On-treatment systolic BP was classified as tightly controlled (<130 mm Hg), controlled (130-139 mm Hg), or uncontrolled (≥140 mm Hg). A Cox proportional hazards model was created adjusting for age, heart failure, diabetes, renal impairment, myocardial infarction, stroke, and smoking. The angina groups and BP control groups were compared using the never-angina group as the reference.

RESULTS

Only in the persistent-angina group was a significant association with mortality observed, with an apparent protective effect (hazard ratio: 0.82, 95% confidence interval: 0.75-0.89, P < 0.0001). Uncontrolled BP was associated with increased mortality risk (hazard ratio: 1.29, 95% confidence interval: 1.20-1.40, P < 0.0001), as were several other known cardiovascular risk factors.

CONCLUSIONS

In hypertensive CAD patients, persistent angina was associated with lower mortality. The observed effect was small compared with other cardiovascular risk factors, such as BP, which were associated with increased mortality.

Prognostic value of reported chest pain for cardiovascular risk stratification in primary care

BACKGROUND

The prognostic significance of chest pain is well established in patients with coronary artery disease, but still ill defined in primary prevention. Therefore, the aim of our analysis was to assess the prognostic value of different forms of chest pain in a large cohort of primary care subjects under the conditions of contemporary modalities of care in primary prevention, including measurement of serum levels of the biomarker NT-pro-BNP.

DESIGN

We carried out a post-hoc analysis of the prospective DETECT cohort study.

METHODS

In a total of 5570 unselected subjects, free of coronary artery disease, within the 55,518 participants of the cross-sectional DETECT study, we assessed chest pain history by a comprehensive questionnaire and measured serum NT-pro-BNP levels. Three types of chest pain, which were any chest pain, exertional chest pain and classical angina, were defined. Major adverse cardiovascular events (MACEs = cardiovascular death, myocardial infarction, coronary revascularization procedures) were assessed during a 5-year follow-up period.

RESULTS

During follow-up, 109 subjects experienced a MACE. All types of reported chest pain were associated with an approximately three-fold increased risk for the occurrence of incident MACEs, even after adjusting for cardiovascular risk factors. Any form of reported chest pain had a similar predictive value for MACEs as a one-time measurement of NT-pro-BNP. However, adding a single measurement of NT-pro-BNP and the information on chest pain resulted in reclassification of approximately 40% of subjects, when compared with risk prediction based on established cardiovascular risk factors.

CONCLUSIONS

In primary prevention, self-reported chest pain and a single measurement of NT-pro-BNP substantially improve cardiovascular risk prediction and allow for risk reclassification of approximately 40% of the subjects compared with assessing classical cardiovascular risk factors alone.

Coronary artery calcification and coronary ischaemia in renal transplant recipients

BACKGROUND

Cardiovascular disease is the leading cause of mortality among renal transplant recipients. Data on the relationship between coronary artery calcification (CAC) and coronary ischaemia in renal transplantation patients are scant. We conducted a study to determine the prevalence and determinants of CAC in these patients; we also examined the frequency of coronary ischaemia in patients with moderate and severe CAC.

METHODS

We used multi-detector spiral computed tomography to examine CAC in 178 consecutive renal transplant recipients. Angina pectoris was sought with the Rose questionnaire. The extent of calcification was measured by Agatston score. Myocardial perfusion scintigraphy was performed in patients with moderate and severe CAC. Multivariate logistic and linear regression analysis was used to evaluate the determinants of CAC presence and CAC score, respectively.

RESULTS

CAC was present in 72 patients (40.4%), mean CAC score was 113.7±275.5 (median: 0 and range: 0-1712). Age, time on transplantation and Rose angina pectoris were the independent determinants of both CAC presence and high CAC scores in all multivariate models. Coronary ischaemia was detected in 17.1% of the patients with moderate-to-severe CAC.

CONCLUSIONS

CAC is highly prevalent in renal transplant recipients; it is associated with symptoms of coronary ischaemia. Time on transplantation is an independent determinant of CAC. Future studies to evaluate the prognostic significance of CAC in these patients are necessary.

Increased mortality among individuals with chronic widespread pain relates to lifestyle factors: a prospective population-based study

PURPOSE

Widespread chronic pain has been related to disability and loss of quality of life, but in a few epidemiological studies also to increased mortality. The aim of this study was to further investigate the relationship between chronic pain, lifestyle factors and all cause mortality.

METHODS

A random sample of an adult (age 25-74) Swedish population (n = 1609) responded to a comprehensive questionnaire on pain, other symptoms, lifestyle, work and socioeconomic factors in 1988. Mortality data for this cohort between 1988 and 2002 were analysed. Survival analysis (Kaplan-Meier) and Cox proportional regression were used to study initially reported factors influencing survival.

RESULTS

Individuals with widespread chronic pain showed an increased mortality risk (hazard ratio, HR = 1.95, CI: 1.26-3.03) compared to the group without chronic pain. Death due to cardiovascular disease accounted for the increased mortality. Adjustment for lifestyle factors eliminated the excess risk.

CONCLUSIONS

Increased mortality among individuals with widespread chronic pain is related to factors like smoking, sleep disturbances and low physical activity. The result emphasises the importance of including lifestyle factors in a cognitive-behavioural rehabilitation process. It remains to be shown whether health promotion activities aimed at lifestyle could change mortality among individuals with chronic pain.

Women tolerate drug therapy for coronary artery disease as well as men do, but are treated less frequently with aspirin, beta-blockers, or statins

BACKGROUND

Women have worse morbidity, mortality, and health-related quality-of-life outcomes associated with coronary artery disease (CAD) compared with men. This may be related to underutilization of drug therapies, such as aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, or statins. No studies have sought to describe the relationship of gender with adverse reactions to drug therapy (ADRs) for CAD in clinical practice.

OBJECTIVE

The aim of this study was to determine the prevalence of ADRs associated with common CAD drug therapies in women and men in clinical practice.

METHODS

In a cohort of consecutive outpatients with CAD, detailed chart abstraction was performed to determine the use of aspirin, beta-blocker, ACE inhibitor, and statin therapy, as well as the ADRs reported for these treatments. Baseline clinical characteristics were also determined to identify the independent association of gender with use of standard drug treatments for CAD.

RESULTS

Consecutive patients with CAD (153 men, 151 women) were included in the study. Women and men were observed to have a similar prevalence of cardiac risk factors and comorbidities, except that men had significantly higher prevalence of atrial fibrillation (30 [19.6%] men vs 15 [9.9%] women; P = 0.03) and significantly lower mean (SD) high-density lipoprotein cholesterol concentrations (45 [16] mg/dL for men vs 55 [19] mg/dL for women; P < 0.001). No significant differences were observed between the sexes in the prevalence of ADRs; however, significantly fewer women than men were treated with statins (118 [78.1%] vs 139 [90.8%], respectively; P = 0.003). After adjusting for clinical characteristics, women were also found to be less likely than men to receive aspirin (odds ratio [OR] = 0.164; 95% CI, 0.083-0.322; P = 0.001) and beta-blockers (OR = 0.184; 95% CI, 0.096-0.351; P = 0.001).

CONCLUSIONS

Women and men experienced a similar prevalence of ADRs in the treatment of CAD; however, women were significantly less likely to be treated with aspirin, beta-blockers, and statins than were their male counterparts. To optimize care for women with CAD, further study is needed to identify the cause of this gender disparity in therapeutic drug use.

Angina pectoris is a stronger indicator of diffuse vascular atherosclerosis than intermittent claudication: Framingham study

OBJECTIVE

To compare implications of Angina Pectoris (AP) and Intermittent Claudication (IC) as indicators of clinical atherosclerosis in other vascular territories.

STUDY DESIGN AND SETTING

Prospective cohort study of cardiovascular disease (CVD) in 5,209 men and women of Framingham, MA, aged 28-62 years at enrollment in 1948-1951, who received biennial examinations during the first 36 years of follow-up. Comparative 10-year incidence of subsequent atherosclerotic CVD in participants with IC and AP relative to a reference sample free of CVD was determined.

RESULTS

On follow-up, 95 CVD events occurred in 186 participants with IC and 206 of 413 with AP. After age, sex, and risk-factor adjustment, the proportion acquiring other CVD was 34.0% for IC and 43.4% for AP. Relative to the reference sample, those with IC had a 2.73-fold higher age and sex-adjusted 10-year hazard of CVD (95% CI 2.21, 3.38) and for AP was 3.17 (95% CI 2.73, 3.69). CVD hazard ratios remained more elevated for AP and statistically significant after standard risk factor adjustment. Risk factors accounted for more of the excess CVD risk associated with IC (34.8%) than AP (9.5%).

CONCLUSION

AP is as useful as IC as a hallmark of diffuse atherosclerotic CVD and an indication for comprehensive preventive measures.

Management of heart failure in elderly people

AIMS

To review currently available knowledge on presentation, clinical features and management of heart failure (HF) in elderly people.

METHODS

To review currently available evidence, we performed a thorough search of several evidence-based sources of information, including Cochrane Database of Systematic Reviews, Clinical Evidence, Evidence-based guidelines from National Guidelines Clearinghouse and a comprehensive MEDLINE search with the MeSH terms: 'heart failure', 'elderly' and 'management'.

RESULTS

A number of features of ageing may predispose elderly people to HF, and may impair the ability to respond to injuries. Another hallmark of elderly patients is the increasing prevalence of multiple coexisting chronic conditions and geriatric syndromes that may complicate the clinical presentation and evolution of HF. Although diagnosis may be challenging, because atypical symptoms and presentations are common, and comorbid conditions may mimic or complicate the clinical picture, diagnostic criteria do not change in elderly people. Drug treatment is not significantly different from that recommended in younger patients, and largely remains empiric, because clinical trials have generally excluded elderly people and patients with comorbid conditions. Disease management programmes may have the potential to reduce morbidity and mortality for patients with HF.

CONCLUSIONS

Heart failure is the commonest reason for hospitalisation and readmission among older adults. HF shows peculiar features in elderly people, and is usually complicated by comorbidities, presenting a significant financial burden worldwide, nevertheless elderly people have been generally excluded from clinical trials, and thus management largely remains empiric and based on evidence from younger age groups.

[Mean length of stay and prognosis in unstable angina. Results from the ARIAM database]

BACKGROUND AND OBJECTIVE

The objective of this project is to investigate the factors predicting mortality and mean length of stay in patients diagnosed with unstable angina (UA) during admission to the Intensive Care Unit or Critical Care Unit (ICU/CCU).

PATIENTS AND METHOD

A retrospective cohort study including all the UA patients listed in the Spanish ARIAM register. The study period comprised from June, 1996 to December, 2003. The follow-up period is limited to the stay in the ICU/CCU. One univariate analysis was performed between deceased and live patients; and another between prolonged and non-prolonged stay patients. Three multivariate analyses were also performed; one to evaluate the factors related to mortality, another to evaluate the variables associated to percutaneous coronary intervention (PCI) and another to evaluate the factors associated to the prolonged mean stay in ICU/CCU.

RESULTS

14,096 patients with UA were included in the study. The UA mortality rate during ICU/CCU admission was 1.1%. Mortality was associated to Killip classification, age, the need for CPR, development of cardiogenic shock, development of arrhythmia (such as VF, sinus tachycardia or high-degree atrioventricular block) and diabetes; whereas patients who smoke were associated to a lower mortality rate. PCI was only performed in 1,226 patients (8.9%), increasing over the years. The PCI-predicting variables were: age, being referred from another hospital, smoking, presenting prior acute myocardial infarction (AMI), complications consisting of cardiogenic shock or high-degree atrioventricular block and being treated with oral beta blockers. The mean length of stay in ICU/CCU was 3.15 (18.65) days (median, 2 days), depending on age, a coronariography having previously been performed, the Killip classification, having required coronariography and PCI or echocardiography or mechanical ventilation, and presenting complications such as angina that is difficult to control, arrhythmia, right ventricular failure or death.

CONCLUSIONS

The factors are associated to mortality were; greater age, diabetes, Killip classification, arrhythmia, cardiogenic shock and the need for CPR, whereas smoking is associated to a lower mortality rate. The patients on whom PCI was performed represent a less severe population. Management has changed over the years, with an increase in PCI. A prolonged mean length of stay is associated to the appearance of arrhythmia, right or left heart failure, angina that is difficult to control, age and PCI.

Survival in relation to angina symptoms and diagnosis among men aged 70-90 years: the Whitehall Study

BACKGROUND

While the excess mortality associated with a diagnosis of angina, myocardial infarction in middle-aged individuals is well established, there is little available evidence on the natural history of angina in population-based studies of older people.

DESIGN

We conducted a 5-year follow-up of 6655 older men aged 67-90 years (mean age 77 years) who participated in the Whitehall Study of London Civil Servants.

METHODS

Survival was examined in relation to a diagnosis of angina or myocardial infarction and to angina symptoms in a population-based study of older men living in the United Kingdom in the late 1990s.

RESULTS

Compared with men without a diagnosis of myocardial ischaemia (n=5219), a diagnosis of angina alone (n=617), myocardial infarction alone (n=421) or both (n=398) were associated with about a threefold, fourfold and sixfold higher risk of death from coronary heart disease, respectively. Median expectation of life at age 70 years was reduced by about 2, 5 and 6 years for those with angina, myocardial infarction, or both, respectively. Current symptoms of angina among those without previously diagnosed angina, was associated with a 2-fold higher risk of coronary heart disease mortality than those without either diagnosis or symptoms.

CONCLUSIONS

Both angina symptoms and diagnosis have a significant adverse effect on survival among men aged 70-90 years highlighting the importance of diagnosis and appropriate treatment of angina in old age.

Epidemiology of angina pectoris: role of natural language processing of the medical record

BACKGROUND

The diagnosis of angina is challenging because it relies on symptom descriptions. Natural language processing (NLP) of the electronic medical record (EMR) can provide access to such information contained in free text that may not be fully captured by conventional diagnostic coding.

OBJECTIVE

To test the hypothesis that NLP of the EMR improves angina pectoris ascertainment over diagnostic codes.

METHODS

Billing records of inpatients and outpatients were searched for International Classification of Diseases, Ninth Revision (ICD-9) codes for angina pectoris, chronic ischemic heart disease, and chest pain. EMR clinical reports were searched electronically for 50 specific nonnegated natural language synonyms to these ICD-9 codes. The 2 methods were compared to a standardized assessment of angina by Rose questionnaire for 3 diagnostic levels: unspecified chest pain, exertional chest pain, and Rose angina.

RESULTS

Compared with the Rose questionnaire, the true-positive rate of EMR-NLP for unspecified chest pain was 62% (95% CI 55-67) versus 51% (95% CI 44-58) for diagnostic codes (P < .001). For exertional chest pain, the EMR-NLP true-positive rate was 71% (95% CI 61-80) versus 62% (95% CI 52-73) for diagnostic codes (P = .10). Both approaches had 88% (95% CI 65-100) true-positive rate for Rose angina. The EMR-NLP method consistently identified more patients with exertional chest pain over a 28-month follow-up.

CONCLUSION

EMR-NLP method improves the detection of unspecified and exertional chest pain cases compared to diagnostic codes. These findings have implications for epidemiological and clinical studies of angina pectoris.

A population study of the long-term consequences of Rose angina: 20-year follow-up of the Renfrew-Paisley study

OBJECTIVE

To examine the long-term cardiovascular consequences of angina in a large epidemiological study.

DESIGN

Prospective cohort study conducted between 1972 and 1976 with 20 years of follow-up (the Renfrew-Paisley Study).

SETTING

Renfrew and Paisley, West Scotland, UK.

PARTICIPANTS

7048 men and 8354 women aged 45-64 years who underwent comprehensive cardiovascular screening at baseline, including the Rose Angina Questionnaire and electrocardiography (ECG).

MAIN OUTCOME MEASURES

All deaths and hospitalisations for cardiovascular reasons occurring over the subsequent 20 years, according to the baseline Rose angina score and baseline ECG.

RESULTS

At baseline, 669 (9.5%) men and 799 (9.6%) women had angina on Rose Angina Questionnaire. All-cause mortality for those with Rose angina was 67.7% in men and 43.3% in women at 20 years compared with 45.4% and 30.4%, respectively, in those without angina (p<0.001). Values are expressed as hazards ratio (HR) (95% confidence interval (CI). In a multivariate analysis, men with Rose angina had an increased risk of cardiovascular death or hospitalisation (1.49 (1.33 to 1.66), myocardial infarction (1.63 (1.41 to 1.85)) or heart failure (1.54 (1.13 to 2.10)) compared with men without angina. The corresponding HR (95% CI) for women were 1.38 (1.23 to 1.55), 1.56 (1.31 to 1.85) and 1.92 (1.44 to 2.56). An abnormality on the electrocardiogram (ECG) increased risk further, and both angina and an abnormality on the ECG increased risk most of all compared with those with neither angina nor ischaemic changes on the ECG. Compared with men, women with Rose angina were less likely to have a cardiovascular event (0.54 (0.46 to 0.64)) or myocardial infarction (0.44 (0.35 to 0.56)), although there was no sex difference in the risk of stroke (1.11 (0.75 to 1.65)), atrial fibrillation (0.84 (0.38 to 1.87)) or heart failure (0.79 (0.51 to 1.21)).

CONCLUSIONS

Angina in middle age substantially increases the risk of death, myocardial infarction, heart failure and other cardiovascular events.

Migraine and other headaches: associations with Rose angina and coronary heart disease

OBJECTIVE

To examine the association between a lifetime history of migraines and other headaches with and without aura and Rose angina and coronary heart disease (CHD).

METHODS

Participants were 12,409 African American and white men and women from the Atherosclerosis Risk in Communities Study, categorized by their lifetime history of headaches lasting > or =4 hours (migraine with aura, migraine without aura, other headaches with aura, other headaches without aura, no headaches). Gender-specific associations of headaches with Rose angina and CHD, adjusted for sociodemographic and cardiovascular disease risk factors, were evaluated using Poisson regression.

RESULTS

Participants with a history of migraines and other headaches were more likely to have a history of Rose angina than those without headaches. The associations were stronger for migraine and other headaches with aura (prevalence ratio [PR] = 3.0, 95% CI = 2.4, 3.7 and PR = 2.0, 95% CI = 1.5, 2.7 for women; PR = 2.2, 95% CI = 1.2, 3.9 and PR = 2.4, 95% CI = 1.4, 3.9 for men) than for migraine and other headaches without aura (PR = 1.5, 95% CI = 1.2, 1.9 and PR = 1.3, 95% CI = 1.1, 1.6 for women; PR = 1.9, 95% CI = 1.2, 2.9 and OR = 1.4, 95% CI = 1.0, 1.8 for men). In contrast, migraine and other headaches were not associated with CHD, regardless of the presence of aura.

CONCLUSIONS

The lack of association of migraines with coronary heart disease suggests that the association of migraine with Rose angina is not related to coronary artery disease. Future research assessing other common underlying pathologic mechanisms is warranted.

WHOQOL-BREF as predictors of mortality: A two-year follow-up study at veteran homes

The main purpose of this study was to evaluate the effectiveness of the brief version of the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire as a predictor of mortality amongst the elderly. A total of 689 male residents of veteran homes, all above the age of 65 years, were randomly selected in 2001. The Taiwan version of the WHOQOL-BREF was administered as the baseline, with each of these subjects being interviewed and subsequently followed up for mortality until the end of 2003. Data on self-reported global health, life satisfaction, medical status, physical performance and health behavior was also collected. Following the death of 105 of the 689 subjects during the 2-year follow-up period, the relative risk (RR) of death was subsequently assessed using Cox's proportional hazard regression analyses. After adjusting for other predictors (age group, chronic diseases, emergency visits, hospitalization, physical performance, regular exercise, self-reported global health and life satisfaction), almost all of the WHOQOL-BREF items and domains failed to predict mortality; the one exception was working capacity levels (score 1-2 vs. score 4-5) which, after adjusting for other predictors, did demonstrate the ability to predict mortality (RR = 1.96, p < 0.05).

Clinical characteristics and methods of treatment of patients with stable coronary heart disease in the primary care settings--the results of the Polish, Multicentre Angina Treatment Pattern (ATP) study

For further improvement of coronary heart disease (CHD) management large epidemiological studies are required to characterise the real population of patients with CHD, treated in the primary care settings, and to evaluate how the guidelines are implemented in the everyday clinical practice. The aim of the Angina Treatment Pattern (ATP) survey was to characterise (i) the population of patients, treated by the primary care physicians for stable CHD, (ii) the methods applied by the primary care physicians to establish diagnosis of CHD and (iii) the pharmacological therapies for CHD. Across Poland, 397 primary care physicians were randomly selected. They recruited 7420 patients (49% men; mean age, 62 +/- 10 years; range: 25-93 years), treated for stable CHD. The duration of CHD was 7.4 +/- 6.6 years (range: 6 months-50 years), 2750 (37%) patients had myocardial infarction. The following risk factors of CHD were present: arterial hypertension in 58%, dyslipidaemia in 52%, smoking in 40%, family history of CHD in 56% and obesity or overweight in 73% of patients. Primary care physicians based a diagnosis of CHD predominantly on a history of anginal pain (in 33% patients), accompanied either by abnormal resting ECG or positive exercise test (in additional 31% patients). Only in 5% of patients, coronary angiography was applied to diagnose CAD. The following groups of drugs have been used: long-acting nitrates in 90%, anti-platelet drugs or anti-coagulants in 71% (aspirin in 65%), angiotensin-converting enzyme inhibitors in 51%, beta-blockers in 48%, calcium antagonists 31%, hypolipaemic drugs in 23% (statins in 10%) and metabolic agents in 16% of patients. Despite an extensive use of classical anti-anginal drugs (including at least one of the following: long-acting nitrates, beta-blockers, calcium antagonists in 95% of patients), 85% of patients still complained of anginal symptoms. Neither prevalence of angina among patients nor nitroglycerin intake depended on the number of anti-anginal drugs taken (monotherapy vs. combination therapy: 82% vs. 86% and 4.9 vs. 5.3 doses weekly, respectively). Among the primary care physicians, the methods used to establish a CHD diagnosis and the mode of CHD management are far from optimal. The results of the ATP study confirm the need for further intensification of activities to improve the process of diagnosis and management among patients with CHD, treated by the family doctors.

The association of Rose questionnaire angina pectoris and coronary calcification in a general population: The Rotterdam Coronary Calcification Study

PURPOSE

The Rose questionnaire is a standardized method of measuring angina pectoris in general populations. Electron-beam computed tomography (CT) is a non-invasive technique to quantify the amount of coronary calcification. In a population-based study, we investigated the association between Rose questionnaire angina pectoris and coronary calcification.

METHODS

The Rotterdam Coronary Calcification Study is embedded in the Rotterdam Study, a population-based study in subjects aged > or = 55 years. Participants of the Rotterdam Coronary Calcification Study underwent an electron-beam CT scan between 1997 and 2000. Coronary calcification was quantified in a calcium score according to Agatston's method. Rose questionnaire angina pectoris was assessed during a home interview. The first 2013 participants were included in the present analyses.

RESULTS

In men, the presence of Rose questionnaire angina pectoris was associated with a 12.9-fold (95% confidence interval: 3.8-43.7) increased risk of a calcium score >1000 (reference: calcium score 0-100). The corresponding relative risk in women was 4.8 (2.0-11.3). Similar results were found when we computed sex-specific quartiles of the calcium score.

CONCLUSIONS

Rose questionnaire angina pectoris is strongly associated with the amount of coronary calcification. Rose questionnaire angina pectoris corresponds better with the amount of coronary calcification in men than in women.

Coronary heart disease: the female heart is vulnerable

During the past decade, an overall theme has emerged, validating the exploration of gender-based differences in coronary heart disease (CHD) as a basis for clinical strategies to improve outcomes for women. Underrepresentation of women in most of CHD and lack of gender-specific reporting in many clinical trials continue to limit the available knowledge and evidence-based medicine needed to devise optimal managements for women with CHD. Control of conventional coronary risk factors provides comparable cardioprotection for men and women. Current evidence fails to show cardiac protection from menopausal hormone therapy. Clinical presentations of coronary heart disease (CHD) and management strategies differ between the sexes. Underutilization of proven beneficial therapies is a contributor to less-favorable outcomes in women. The contemporary increased application of appropriate diagnostic, therapeutic, and interventional managements has favorably altered the prognosis for women, particularly when the data are adjusted for baseline characteristics. Better education of women during office visits, earlier and more aggressive control of coronary risk factors, and a greater index of suspicion regarding chest pain and its appropriate evaluation may help to reverse the trend of late referral and late intervention. Research indicates that behavioral changes on the part of women and reshaping of practice patterns by their health care providers may dramatically reduce the number of women disabled and killed by CHD each year.

Association between depression and elevated C-reactive protein

OBJECTIVE

Depression has been related to a higher risk of developing coronary heart disease, but the mechanism that accounts for this association is unclear. Because atherosclerosis is an inflammatory process, depression could increase the risk of coronary heart disease by inducing or promoting inflammation. The objective of the present study was to investigate the association between history of major depressive episode and presence of low-grade systemic inflammation as measured by serum C-reactive protein (CRP).

METHODS

We analyzed data from the Third National Health and Nutrition Examination Survey, a representative sample of the US population from 1988 to 1994. Participants included a total of 6149 individuals aged 17 to 39 years who were free of cardiovascular diseases and chronic inflammatory conditions. The main predictor variable of interest was lifetime history of a major depressive episode as assessed by means of the Diagnostic Interview Schedule. The main outcome variable was the presence or absence of an elevated CRP level (> or =22 mg/dl).

RESULTS

Among men, history of a major depressive episode was associated with elevated CRP, particularly for recent episodes (up to 6 months before assessment). In multivariate analyses, men with a history of major depressive episode had 2.77 times higher odds of elevated CRP compared with never-depressed men (95% confidence interval, 1.43-5.26). The adjusted odds ratio was 3.81, 3.98, 1.51, and 1.52 for men who had their last major depressive episode less than 1 month before, 1 to 6 months before, 7 to 12 months before, and more than 12 months before assessment, respectively (p for trend =.004). In women, a comparable association between depression and CRP was quite weak and not significant.

CONCLUSIONS

A recent history of major depressive episode is strongly associated with elevated CRP in men aged 17 to 39. In this group, low-grade systemic inflammation could represent a mechanism linking depression to cardiovascular risk.

Prescription of anti-anginal drugs in relation to exercise tests and coronary angiography. A 1-year population-based study of two Danish counties

BACKGROUND: The cardiac diagnostic examination activity in a population should ideally mirror age and gender characteristics of the prevalence of ischemic heart disease. In this study, the prescription of anti-anginal drugs in relation to morbidity and mortality brought on by ischemic heart disease, and in relation to exercise tests and coronary angiography, is analyzed. METHODS: The study population comprised two Danish counties with a total of 896,954 inhabitants. We obtained data on all prescriptions of nitrates, adrenergic beta-antagonists, and calcium channel blockers from regional pharmaceutical registers. Data on all patients who took an exercise test or underwent coronary angiography were derived from regional health authority registers. Data on ischemic heart mortality and on the incidence of myocardial infarction were gathered from the national register of causes of death and hospital registers. RESULTS: Only patients receiving nitrates had an age and gender profile matching that of those who died from ischemic heart disease or who suffered from myocardial infarction (correlation coefficients 0.95-0.99). Judging from the prescription of nitrates, relatively few elderly patients, especially women older than 60-69 years, were referred for a cardiac examination. CONCLUSIONS: The prescription of nitrates seems useful as a surrogate marker for ischemic heart disease. Elderly patients, especially women, seem to be treated with anti-anginal medication without any diagnostic evaluation.

Progressive versus catastrophic loss of the ability to walk: implications for the prevention of mobility loss

OBJECTIVES

Loss of mobility is an important functional outcome that can have devastating effects on quality of life and the ability of older persons to remain independent in the community. Although a large amount of research has been done on risk factors for disability onset, little work has focused on the pace of disability progression. This study characterizes the development of severe walking disability over time and evaluates risk factors and subsequent mortality as they relate to mobility disability with progressive or catastrophic onset.

DESIGN

Population-based prospective cohort study with annual follow-up assessments for up to 7 years

SETTING

Three communities of the Established Populations for Epidemiologic Studies of the Elderly.

PARTICIPANTS

There were 5,355 persons not disabled at baseline and the first follow-up who had adequate data available to classify mobility disability during subsequent follow-ups.

MEASUREMENTS

Severe mobility disability was defined as the need for help from a person to walk across a room or inability to walk across a room. Those developing severe mobility disability were classified as having progressive mobility disability if they had been unable to walk half a mile in either of the prior 2 years. They were classified as having catastrophic mobility disability if they reported having been able to walk half a mile in two previous annual interviews.

RESULTS

The overall incidence of severe mobility disability was 11.6 cases/1,000 person years. Those age 85 and older or having three or more chronic conditions at baseline were significantly more likely to develop progressive disability than catastrophic disability. Stroke, hip fracture, and cancer occurring during follow-up were associated with very high risk of severe mobility disability. For stroke and hip fracture, the risk was twice as high for catastrophic disability as for progressive disability, but this difference did not reach statistical significance. Risk for catastrophic disability from cancer was significantly greater than for progressive disability. Half of catastrophic disability subjects had stroke, hip fracture, or cancer in the year immediately preceding this disability. Incident heart attack did not predict severe mobility disability. Among those who developed severe mobility disability, type of disability did not influence subsequent survival for the first 3 years, but beyond 3 years those with catastrophic disability had a relative risk of death of 0.4 (95% confidence interval 0.2-0.9) compared with those with progressive disability.

CONCLUSION

The observation that risk factors and mortality outcomes were both different for progressive and catastrophic mobility disability supports the value of ascertaining the pace of disability development as a useful characterization of disability. Further progress in developing prevention and treatment strategies may be made by taking the pace of disability development into account.

The performance of the Rose angina questionnaire in South Asian and European origin populations: a comparative study in Newcastle, UK

BACKGROUND

The Rose angina questionnaire has been extensively used in different cultural settings, but may not perform consistently in different ethnic groups. We set out to assess the performance of the Rose angina questionnaire in UK South Asians compared with Europeans.

METHODS

Data on major ECG abnormalities, possible or definite Rose questionnaire angina and diagnosed angina were collected from an age- and sex-stratified random sample of 1509 adults from European, Indian, Pakistani and Bangladeshi ethnic groups.

RESULTS

The ECG abnormalities were commoner in South Asians than Europeans (6% versus 2% in men). The prevalence in both South Asian and European men of possible Rose angina and diagnosed angina was 18% and 8%, respectively, but definite Rose angina was less common in South Asians (3% versus 6%). Definite Rose angina showed lower sensitivity for other measures in South Asians than in Europeans: sensitivity for a doctor's diagnosis was 21% in South Asian and 37% in European men. For possible Rose angina, the corresponding figures were 81% and 84%. Similar patterns were seen in women.

CONCLUSIONS

The performance of the Rose angina questionnaire was sufficiently inconsistent to warrant further work to achieve greater cross-cultural validity. Possible Rose angina performed more consistently across ethnic groups than definite Rose angina and pending further validation studies may be the most appropriate form to use.

Exercise rehabilitation of older patients with cardiovascular disease

As the population of elderly patients with cardiovascular disease continues to increase, much research needs to be done with the goal of maintaining physical functioning and personal independence in this population. It is of particular importance to determine whether training programs can improve physical functioning in the most severely disabled older coronary patients. Effects of cardiac rehabilitation programs on other outcome measures, including psychosocial outcomes, lipid levels, insulin levels, and body composition require better study. Finally, the economic benefits of cardiac rehabilitation in the older coronary patients has received little attention, although early reports are promising. In summary, the older population with coronary disease is characterized by high rates of disability. Exercise training has been demonstrated to be safe and to improve strength, aerobic fitness capacity, endurance and physical function. It remains to be seen whether exercise training can reverse or prevent disability in a broad population of older patients with cardiovascular disease. If successful, cardiac rehabilitation programs will pay great medical, social, and economic dividends in this population.

The relationship between heart problems and mortality in different social classes

The aim of this study is to analyze how relative mortality risk varies between persons with and without heart problems in different social classes. Cox proportional hazards regression was used to analyze relative mortality risk for the period 1968-1996 for a Swedish nationally representative sample of 4585 persons born between 1892 and 1942, and interviewed 1968. Survivors from the original sample were also interviewed in 1974, 1981 and 1991 or 1992. "Heart problems" is defined as the presence of three mild or one severe symptom associated with circulatory problems. Social class is based on occupation. The relative mortality risk varied significantly between social classes and between persons with and without heart problems, among both men and women. These differences were smaller among women than among men. The main results are that there are significant additive interactions between social class and heart problems among men. Men from lower social classes have a more elevated mortality risk than men from higher social classes when they have a heart problem. Among white-collar workers the coefficient of the difference between men with and without heart problems was 0.53. The corresponding difference was significantly larger among workers (1.59, P = 0.01), thus demonstrating an additive interaction. The difference was even greater (1.86) among "unclassifiable" men--those who could not report an occupation that could be coded into a social class, mainly because they were long-term unemployed or on early-retirement pensions. Among women, the mortality difference between white-collar workers with and without heart problems was 0.85. None of the mortality differences between those with and without heart problems in other social classes differed significantly from those of white-collar workers. The mortality difference between women with and without heart problems was, however, large (2.34) among the "unclassifiable". This difference is even larger than the corresponding difference among men.

Pulse pressure and risk for myocardial infarction and heart failure in the elderly

OBJECTIVES

We sought to determine whether pulse pressure (PP), a measure of arterial stiffness, is an independent predictor of the incidence of coronary heart disease (CHD), congestive heart failure (CHF) and overall mortality among community-dwelling elderly.

BACKGROUND

Current hypertension guidelines classify cardiovascular risk on the basis of elevated systolic blood pressure (SBP) or diastolic blood pressure (DBP) without considering their combined effects. Recent studies suggest that PP is a strong predictor of cardiovascular end points, but few data are available among community elderly.

METHODS

The study sample included 2,152 individuals age > or =65 years, who were participants in the Established Populations for Epidemiologic Study of the Elderly program, free of CHD and CHF at baseline and still alive at one year after enrollment. Blood pressure was measured at baseline. Incidence of CHD, incidence of CHF and total mortality were monitored in the following 10 years.

RESULTS

There were 328 incident CHD events, 224 incident CHF events and 1,046 persons who died of any cause. Pulse pressure showed a strong and linear relationship with each end point. After adjusting for demographics, comorbidity and CHD risk factors, a 10-mm Hg increment in PP was associated with a 12% increase in CHD risk (95% confidence interval [CI], 2% to 22%), a 14% increase in CHF risk (95% CI, 5% to 24%), and a 6% increase in overall mortality (95% CI, 0% to 12%). While SBP and mean arterial pressure (MAP) also showed positive associations with the end points, PP yielded the highest likelihood ratio chi-square. When PP was entered in the model in conjunction with other blood pressure parameters (SBP, DBP, MAP or hypertension stage, respectively), the association remained positive for PP but became negative for the other blood pressure variables. The effect of PP persisted after adjusting for current medication use and was present in normotensive individuals and individuals with isolated systolic hypertension but not in individuals with diastolic hypertension.

CONCLUSIONS

Elevated PP is a powerful independent predictor of cardiovascular end points in the elderly.

Prevalence of angina pectoris in Spain. PANES Study group

The frequency of coronary heart disease in a community is usually measured by myocardial infarction incidence and mortality rates. The measurement of the prevalence of angina pectoris may, however, become a convenient way of assessing coronary heart disease morbidity in the future. The aim of this study was to determine the prevalence of angina and validity of the Rose questionnaire in the Spanish population aged from 45 to 74 years. A cross-sectional study was conducted in 10,248 subjects (45-74 years), representative of the Spanish population. The WHO Rose questionnaire was used and a construct validation against regional mortality rates and cardiovascular risk factor prevalence was devised. The overall angina prevalence increased with age both in men and women, but was higher in the latter (7.3% and 7.7%, respectively). Angina prevalence also increased with the number of cardiovascular risk factors present and correlated with regional CHD mortality rates (r = 0.66). Sensitivity and specificity results of the Rose questionnaire were low when tested against exercise test (52.9% and 52.1%, respectively). As conclusions, Rose questionnaire is a reliable tool for assessing angina prevalence in the Spanish population which is similar to that of other industrialized countries with higher myocardial infarction morbidity and mortality.

Coronary heart disease. Stable and unstable syndromes

CHD in the elderly population will continue to be a source of major concern because of the increasing costs entailed and uncertainties about how the widespread array of diagnostic and therapeutic interventions, often expensive and sometimes hazardous, should be applied. Financial, political, and health policy decisions will continue to occupy much attention, but it is likely that philosophic considerations about aging and death, both from the individual and the societal perspective, will be of paramount importance of deciding how the substantial resources available to the elderly will be used. Randomized, controlled trials are unlikely to play a major role in resolution of management dilemmas in the elderly because of the extraordinary heterogeneity in this population. Registries (databases) involving carefully prospectively collected key variables are likely to be a more effective approach. Critical characterization of complications of procedures, adverse drug reactions, and collection of follow-up data on functional status are among the critical questions, and these can be answered by registry studies. Algorithms and clinical rules developed in younger cohorts are not directly transferable to the elderly cardiovascular patients, further emphasizing the need for prospectively collected, syndrome-specific data. Treatments convincingly demonstrated to reduce mortality in absolute terms more in the elderly than in the young are underused. The heterogeneity of aging emphasizes the wide variability in patients' ability to withstand the stress of procedures and complications of disease and makes clear the need to consider physiologic reserve and biologic age rather than chronology. With better characterization of biologic age and physiologic reserve, more precise estimates of outcomes of therapies and interventions can be made, and patients can be given better information and with their families have more realistic expectations. Better-informed decisions will result. Biologic age will be multifactorial, involving cognitive, emotional, physical, and nutritional attributes as well as specific organ function (lung, kidney, liver) because no single feature can characterize the total elderly patient. The concept of competing risks among the cardiovascular disease being treated, comorbidity, risks of study, and life expectancy will evolve because even the most successful therapy will have limited effect on longevity in the very old. Although important research at the cellular and molecular level will characterize and provide better understanding of the aging process, it is not likely that this basic information will be immediately useful in the management of the large number of elderly patients with major cardiovascular disease. Preventive measures, including physical exercise, mental stimulation, avoidance of depression, good nutrition, and abstinence from tobacco use, are useful approaches to postpone or ameliorate the consequences of aging and allow patients to tolerate cardiovascular diseases better when they become manifest.

Comparison of the Heart and Estrogen/Progestin Replacement Study (HERS) cohort with women with coronary disease from the National Health and Nutrition Examination Survey III (NHANES III)

BACKGROUND

The Heart and Estrogen/Progestin Replacement Study (HERS) is the first large clinical trial designed to test the efficacy of postmenopausal estrogen/progestin therapy for secondary prevention of coronary heart disease (CHD). To examine the representativeness of the HERS cohort to the general population of postmenopausal women with CHD, we compared the baseline cardiovascular risk factor data from HERS with similar data from women presumed to have CHD from the National Health and Nutrition Examination Survey (NHANES) III.

METHODS

Age, race, and cardiovascular disease risk factors were compared in the 2763 postmenopausal women younger than 80 years old, with a uterus, and with documented CHD in HERS versus 145 similarly aged women with clinical or electrocardiographic evidence of CHD from phase I of NHANES III.

RESULTS

There were fewer current smokers in HERS (13%) than in the NHANES cohort (21.7%, p = 0.05). Similarly, a history of hypertension was less prevalent in HERS (58.6%) than in the NHANES cohort (69.3%, p = 0.03). Women with fasting triglyceride levels >3.39 mmol/L or fasting glucose levels >16.6 mmol/L were excluded from HERS, resulting in fewer diabetics (22.9% vs 29.5%, p = 0.26) and lower serum triglyceride levels (1.88 mmol/L vs 2.25 mmol/L, p = 0.19) in HERS versus the NHANES cohort. Systolic and diastolic blood pressure, body mass index, physical activity, and total LDL and HDL cholesterol were not significantly different between the two groups.

CONCLUSIONS

The HERS cohort had fewer CHD risk factors than women with myocardial infarction or angina in NHANES III, although comparison is hindered by differences in selection criteria. The many women with diabetes and hypertriglyceridemia in the NHANES cohort emphasizes the importance of testing strategies for secondary prevention of CHD in this high-risk subgroup.

Safety and results of dobutamine stress echocardiography in women versus men and in patients older and younger than 75 years of age

The purpose of this retrospective study was to examine 732 consecutive patients who underwent dobutamine stress echocardiography (DSE) in order to compare the safety and result profiles of this test between women versus men and in patients > or = 75 and < 75 years of age. Our study included 416 women (57%) and 316 men (43%; mean age 62 +/- 12 years [range 16 to 93]). Patients were divided into 3 age groups: (1) group I (n = 179): < 55 years (mean 47 +/- 6), (2) group II (n = 447): 55 to 74 years (mean 64 +/- 5), and (3) group III (n = 106): > or = 75 years (mean 80 +/- 4). DSE was more likely to have negative results in women than in men (prevalence of positivity = 20% vs 31%, p = 0.001), but DSE had a similar safety profile in both genders. Women required lower doses of dobutamine and atropine to reach an end point. There was a similar incidence of test positivity in older and younger patients (23% in group I, 24% in group II, and 30% in group III, p = NS). DSE was generally a safe test in patients > or = 75 years, but there was a different safety profile in the elderly group compared with younger patients--specifically, more frequent asymptomatic hypotension (7% in group I, 13% in group II, and 25% in group III, p = 0.0002) and ventricular arrhythmias (26% in group I, 30% in group II, and 41% in group III, p = 0.04), but less frequent chest pain (32% in group I, 23% in group II, and 17% in group III, p = 0.009). Multivariate analysis suggested that the baseline usage of beta blockers was also a major determinant of the safety and ischemia profile during DSE. In conclusion, there were significant gender- and/or age-specific differences in the safety and test result profile of DSE. These differences should be considered when performing or interpreting DSE, particularly in women and in patients aged > or = 75 years.

The relationship between the supply of cardiac catheterization laboratories, cardiologists and the use of invasive cardiac procedures in northern New England

OBJECTIVES

Utilization rates of coronary angiography and cardiac revascularization have been found to vary between areas. This study addresses the relationship between resource supply and procedure rates.

METHODS

We compared the association of per capita catheterization laboratories, per capita cardiologists and multi-provider markets (where more than one hospital offers coronary angiography services) with the utilization rates for angiography and cardiac revascularization in northern New England, USA. Administrative data were used to capture invasive cardiac procedures. Small area analyses were used to create coronary angiography service areas. Linear regression methods were used to measure associations between the resource supply and utilization rates.

RESULTS

Variation in the use of invasive cardiac procedures was strongly associated with the population-based availability of catheterization facilities and multi-provider markets and unrelated to cardiologist supply or need (as reflected in the hospitalization rates for myocardial infarction). In the multivariate model, an increase of 1 catheterization laboratory per 100,000 population was associated with an increase in the angiography rate of 1.62 per 1000 population; those service areas with multi-provider markets were associated with an additional increase in the angiography rate of 1.27 per 1000 population (R2 = 0.84, P = 0.0006). There was a moderately strong relationship between the catheterization laboratories per capita and the revascularization rates (R2 = 0.43, P = 0.029). Angiography rates were highly associated with cardiac revascularization rates: an increase in the angiography rate of 1 per 1000 population was associated with a 0.46 per 1000 increase in the cardiac revascularization rate (R2 = 0.85, P = 0.0001).

CONCLUSIONS

Our work suggests that current efforts to address variation in cardiac procedures through activities such as appropriateness criteria, guidelines and utilization review are misdirected and should be redirected towards capacity, in this case the supply of catheterization facilities.

Serum albumin and physical function as predictors of coronary heart disease mortality and incidence in older persons

The role of traditional risk factors in predicting coronary heart disease (CHD) among men and women aged 65 years and over has been extensively debated, but the search for risk factors that are distinctive in the elderly is still ongoing. The relation of serum albumin levels and physical disability to risk of CHD morality and incidence was prospectively assessed in a cohort of 4116 men and women, aged 71 years and over, who were evaluated in 1987-1989 and followed for a mean of 4.0 years. Outcome events were based on death certificates and Medicare hospitalization records. Analyses were adjusted for major CHD risk factors. There were 275 CHD deaths (16.8/1000 person-years) among all participants and 503 incident (fatal and nonfatal) CHD events (39.4 per 1000 person-years) among participants free of prevalent CHD during the observation period. The relative risk (RR) of CHD morality for women with an albumin concentration < 38 g/liter was 2.5 times higher than for women with albumin > 43 g/liter (RR 2.5; 95% confidence interval [CI], 1.4-4.6). There was a significant and graded increase in CHD incidence with decreasing albumin concentration in women but not in men. The presence of physical disability doubled the risk of CHD mortality among both men and women, an increase in risk that was comparable to that imposed by a previous myocardial infarction and was independent of other coronary risk factors. Disability had a lesser impact on CHD incidence, which was significant only in women. Low albumin concentration (< 38 g/liter) identifies a group of women at higher risk of CHD mortality and incidence. Physical disability is an independent predictor of CHD mortality in both men and women and for CHD incidence only in women.

The Jerusalem seventy-year-old longitudinal study. I: Description of the initial cross-sectional survey

The main objectives of our first cross-section of a longitudinal study of a cohort of 70 year olds in Jerusalem, are to survey the social and medical conditions of the heterogeneous elderly population and to contribute to the knowledge of aging processes for specific age-groups. Whereas, most previous surveys were conducted on homogeneous and stable population groups, the elderly of Jerusalem provide the basis for ethnographic comparisons and for assessing the impact of profound historical and personal changes. From a representative systematic sample (from a geographically sorted electoral register) of 759 persons, 605 persons replied to our home-visit questionnaire gathering data on migration history, dwelling conditions, health status, health service utilization, employment status, activities of daily living, social support, use of drugs and war experience. Later on, 463 persons attended our geriatric research institute where we gathered information from in-depth anamnesis and physical examination, as well as cognitive and psychological tests. In addition, a battery of biochemical and hematological blood tests were performed as well as urine analysis and culture, ECG and pulmonary function tests. The heterogeneity of our cohort population is demonstrated by the finding that 84% were born in 40 different countries outside of Israel. In contrast, in the seventy-year old population studied in Gothenburg, Sweden, only 3% were not native born. In the years 1996, 2001 and 2006, our initial study cohort will be re-examined and compared to control groups representing states of no-survey intervention until ages 75, 80 and 85 years old. This background paper describes the study design, protocols and procedures. The responders were found to be representative of the 70 year old Jewish population in Jerusalem as a whole, in terms of mortality and hospital utilization rates. The results of the study to be reported in subsequent papers will allow conclusions regarding all 70 year old Jews in Jerusalem to be made.

A truncated species of apolipoprotein B (B67) in a kindred with familial hypobetalipoproteinemia

We describe a kindred in which the proband and 6 of his 12 children have hypobetalipoproteinemia. The plasma lipoproteins of the affected subjects contained a unique species of apolipoprotein (apo) B, apo B67, in addition to the normal species, apo B100 and apo B48. The size of apo B67 and immunochemical studies with a panel of apo B-specific antibodies indicated that apo B67 was a truncated species of apo B that contained approximately the amino-terminal 3,000-3,100 amino acids of apo B100. Sequencing of genomic apo B clones revealed that affected family members were heterozygous for a mutant apo B allele containing a single nucleotide deletion in exon 26 (cDNA nucleotide 9327). This frameshift mutation is predicted to result in the synthesis of a truncated apo B containing 3,040 amino acids. Apo B67 is present in low levels in the plasma but is easily detectable within the very low density lipoprotein and low density lipoprotein fractions. Examination of the proband's immediate family revealed seven normolipidemic subjects and seven subjects with hypobetalipoproteinemia. In the affected subjects, the mean total and low density lipoprotein cholesterol levels were 120 and 42 mg/dl, respectively. A significantly higher mean high density lipoprotein cholesterol level was found in the affected subjects (75 vs. 55 mg/dl). We hypothesize that the elevated high density lipoprotein cholesterol levels in subjects heterozygous for the apo B67 mutation may be metabolically linked to the low levels of apo B-containing lipoproteins in their plasma.

Morbidity and disability in older persons in the years prior to death

BACKGROUND

A large proportion of the disease and disability which affects older persons occurs in the years just prior to death. Little prospective evidence is available which quantifies the burden of morbidity and disability during these years.

METHODS

In three community-based cohorts of persons age 65 and older, chronic conditions and disability were evaluated for the three years prior to death in 531 persons who had three annual assessments and then died within one year of the third assessment. Number of chronic conditions, prevalence of disability in activities of daily living (ADLs), and prevalence of disability on a modified Rosow-Breslau scale were determined for these decedents and compared to 8821 members of the cohorts known to have survived.

RESULTS

Prevalence rates of disease and disability increased during the follow-up for both decedents and survivors, with decedents generally having higher rates than survivors. Disability rates prior to death, but not the number of diseases, increased with increasing age at death. The odds ratio for disability in ADLs at any of the three assessments for decedents versus survivors ranged from 3.0 to 4.2 in the three communities. In each community the odds ratio for ADL disability was higher in women decedents versus survivors than in men decedents versus survivors.

CONCLUSIONS

These results have important implications for disability levels in future older populations in which death is projected to occur at increasingly higher ages.