Association of night-time sleep duration and daytime napping with all-cause and cause-specific mortality in older British men: Findings from the British Regional HeartStudy

Short and long night-time sleep and daytime napping in young and middle-aged populations were associated with increased mortality, but it is unclear in very older people. The aim of this prospective study was to assess the associations in people aged >70 years. We examined the data of British Regional Heart Study, which included 1722 men aged 71-92 years and had night-time sleep duration and daytime napping measured at baseline and were followed up for nine years. There were 597 deaths. Compared to night-time sleep at 7-<8 h, age-adjusted hazard ratio of all-cause mortality in participants sleeping <6 h was 1.04 (95% CI 0.80-1.35), 1.07 (0.85-1.34) in 6-<7 h, 1.04 (0.83-1.30) in 8-<9 h and 0.93 (0.65-1.33) in ≥9 h. Further adjustments for other co-variables still showed no association, and neither the association with cardiovascular mortality nor non-cardiovascular mortality. Daytime napping, however, was associated with mortality. After adjustment for age, smoking, physical activity, obesity, cardiovascular diseases, diabetes, frailty, general health, anti-hypertensive medication and C-reactive protein level, hazard ratio of all-cause mortality in participants with daytime napping >1-h versus no napping was 1.62 (1.18-2.22) and hazard ratio of non-cardiovascular mortality was 1.77 (1.22-2.57). The fully adjusted hazard ratio of cardiovascular mortality was not significantly increased 1.26 (0.69-2.28), although age-adjusted hazard ratio was significant 1.94 (1.20-3.16). In the elderly men, daytime napping was independently associated with increased all-cause and non-cardiovascular mortality, while its association with cardiovascular mortality could be explained by cardiovascular risk factors and co-morbidities. Night-time sleep duration was not associated with mortality risk.

The influence of neighbourhood-level socioeconomic deprivation on developing type 2 diabetes in older men: a longitudinal analysis of the British Regional Heart Study cohort data

BACKGROUND

Evidence from the British longitudinal studies on the influence of neighbourhood-level socioeconomic deprivation in older men on developing type 2 diabetes mellitus is scarce. This study investigates the prospective associations of neighbourhood-level deprivation and individual socioeconomic position with type 2 diabetes mellitus incidence in older men.

METHODS

The British Regional Heart Study comprises a cohort of 4252 men aged 60-79 years in 1998-2000 from 24 towns across the UK. Neighbourhood-level deprivation was based on the country specific 2004-05 Index of Multiple Deprivation (IMD) quintiles for participants' postcode of residence at baseline. Individual socioeconomic position was defined as occupational social class based on longest-held occupation at recruitment. Participants with prevalent diabetes were excluded. The incidence of type 2 diabetes mellitus was ascertained from biannual reviews of primary care records over 18 years of follow-up. Cox proportional hazard models were undertaken to examine associations.

FINDINGS

The incidence of type 2 diabetes mellitus cases observed was 368 (9·9%), amongst the 3706 male participants. Age-adjusted rates of type 2 diabetes mellitus increased from IMD quintile 1 (least deprived) to quintile 4 (second most deprived), before decreasing in quintile 5. Compared with quintile 1, the age and individual social class adjusted hazard ratio (aHR) in quintile 4 was 1·52 (95% CI 1·09-2·13), remaining significant after further adjustments for obesity and family history of type 2 diabetes mellitus. Participants in the lowest social class had the highest rates of type 2 diabetes mellitus. The aHR by age and IMD scores for type 2 diabetes mellitus in the lowest social class compared with the highest social class was 2·12 (95% CI 1·15-3·89).

INTERPRETATION

Neighbourhood-level and individual-level socioeconomic factors remain important predictors of developing type 2 diabetes mellitus in older men, demonstrating that inequalities persist in later life. Inequalities in diabetes and its underlying modifiable risk factors need to be addressed to reduce the burden of this disease in socioeconomically deprived older-age populations.

FUNDING

None.

Haematological variables and risk of future venous thromboembolism in the British Regional Heart Study on men. Combined D-dimer and APTT as a predictive test for thromboembolism?

We examined the associations between haematological and inflammatory variables with future venous thromboembolism (VTE), in 3494 men aged 60-79 years, with no previous history of VTE or myocardial infarction, who were not receiving oral anticoagulants. After a mean follow-up period of 18 years, there were 149 confirmed cases of fatal or non-fatal VTE (deep vein thrombosis and/or pulmonary embolism). Among classical cardiovascular risk factors, only obesity and cigarette smoking were associated with VTE risk. After adjustment for age, obesity and smoking, VTE risk was associated with coagulation factor VIII, factor IX, von Willebrand factor (VWF), activated partial thromboplastin time (APTT), and fibrin D-dimer. Hazard ratios (95% CI) for top to bottom quarters (bottom to top for APTT), were respectively 2.17 (1.37, 3.44), 2.15 (1.30, 3.53), 2.02 (1.27, 3.22), 2.43 (1.47, 4.02) and 3.62 (2.18, 6.08). The 11% of men with both the shortest APTT and highest D-dimer combined had a 5.02 (2.37, 10.62) higher risk of VTE. VTE risk was not associated with fibrinogen, factor VII or activated protein C resistance; full blood count variables or with inflammatory markers, plasma viscosity, C-reactive protein or interleukin-6. The combination of D-dimer and APTT merits evaluation as an adjunct to VTE risk prediction scores.

Social relationships and the risk of incident heart failure: results from a prospective population-based study of older men

Aims

Limited social relationships, particularly in older adults, have been implicated as a risk factor for cardiovascular disease. However, little is known about the associations between poor social relationships and heart failure incidence.

Methods and results

Prospective study of socially representative men aged 60–79 years drawn from general practices in 24 British towns and followed up for a maximum of 18 years. A total of 3698 participants with no previous diagnosis of heart failure were included. Information on social relationships was based on a combination of marital status, living circumstances, and social contacts with friends and family. These provided information on contact frequency, contact satisfaction, and a social relationship score (low to high) combining frequency and satisfaction with contact. Heart failure included both incidents non-fatal heart failure and death from heart failure. Among 3698 participants, 330 developed heart failure. Men with low compared to high frequency of contact with family and friends had an increased risk of incident heart failure [hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.15–2.18]; this remained statistically significant after adjustment for social class, behavioural, and biological risk factors. Low compared to high scores for satisfaction with contacts was associated with increased risk of heart failure (adjusted HR = 1.54; 95% CI 1.14–2.07). Lower social relationship scores (combining frequency and satisfaction with contact) were associated with greater risk of incident heart failure (adjusted HR = 1.38, 95% CI 1.02–1.87). Marital status and living alone were not significantly associated with heart failure.

Conclusion

Weaker social relationships appear to increase the risk of developing heart failure in older age. Further research is needed to investigate pathways underlying these associations and to test whether interventions to strengthen social relationships can reduce the risk of heart failure.

Vitamin D deficiency, impaired lung function and total and respiratory mortality in a cohort of older men: cross-sectional and prospective findings from The British Regional Heart Study

OBJECTIVES

Vitamin D deficiency is associated with chronic obstructive pulmonary disease (COPD). We examined the cross-sectional association between 25-hydroxyvitamin D (25(OH)D) and lung function impairment and assessed whether vitamin D deficiency is related to long-term mortality in those with impaired lung function.

DESIGN

Prospective study SETTING: General practices in the UK.

PARTICIPANTS

3575 men aged 60-79 years with no prevalent heart failure.

OUTCOME MEASURES

Airway obstruction and mortality. The Global Initiative on Obstructive Lung diseases (GOLD) spirometry criteria was used to define airway obstruction.

RESULTS

During the follow-up period of 20 years, there were 2327 deaths (114 COPD deaths). Vitamin D deficiency was defined as serum 25(OH)D levels<10 ng/mL; insufficiency as 25(OH)D 10-19 ng/mL; sufficient as 25(OH)D>20 ng/mL. In cross-sectional analysis, vitamin D deficiency was more prevalent in those with moderate COPD (FEV/FVC <70% and FEV₁ 50 to <80%; FEV₁, forced expiratory volume in 1 s and FVC, forced vital capacity) and severe COPD (FEV/FVC <70% and FEV₁ <50%) but not in those with mild COPD (FEV/FVC <70% and FEV₁>80%) or restrictive lung disease (FEV₁/FVC >70% and FVC <80%) compared with men with normal lung function . Vitamin D deficiency was associated with increased risk of total and respiratory mortality in both men with COPD and men with restrictive lung disease after adjustment for confounders and inflammation. The adjusted HRs (95% CI) for total mortality comparing levels of 25(OH)D<10 ng/mL to 25(OH)D>=20 ng/mL were 1.39 (1.10 to 1.75), 1.52 (1.17 to 1.98), 1.58 (1.17 to 2.14) and 1.39 (0.83 to 2.33) for those with no lung impairment, restrictive lung function, mild/moderate COPD and severe COPD, respectively.

CONCLUSION

Men with COPD were more likely to be vitamin D deficient than those with normal lung function. Vitamin D deficiency is associated with increased all-cause mortality in older men with no lung impairment as well as in those with restrictive or obstructive lung impairment.

Adult height and incidence of atrial fibrillation and heart failure in older men: The British Regional Heart Study

Aims

Taller stature has been associated with increased risk of atrial fibrillation (AF). AF and heart failure (HF) often co-occur but the association between height and risk of HF in older adults has not been well studied. We have examined the association between height and incident AF and incident HF in older adults.

Methods

Prospective study of 3346 men aged 60–79 years with no diagnosed HF, myocardial infarction or stroke at baseline (1998–2000) followed up for a mean period of 16 years, in whom there were 294 incident HF cases and 456 incident AF. Men were divided into 5 height groups: <168.2, 168.2–172.5, 172.6–176.9, 177.0–183.0 and >183.0 cms based on the 25th, 50th, 75th and 95th centiles distribution of height.

Results

CVD risk factors tended to decrease with increasing height but a positive association was seen between height and electrocardiographic QRS duration and incident AF. Both short stature (<168.2 cm) and tall stature (>183.0 cm) was associated with significantly increased risk of HF in age-adjusted analysis compared to those in the second height quartile [HR (95 %CI) = 1.62 (1.15, 2.26) and 2.04 (1.23, 3.39) respectively]. In short men the increased risk remained after adjustment for adverse CVD risk factors; in tall men the association was largely associated with AF and QRS duration.

Conclusion

Tall stature is associated with significantly increased risk of AF leading to increased risk of HF. Short stature was associated with increased HF risk which was not explained by known adverse CVD risk factors.

Cardiovascular Health and Stroke in Older British Men: Prospective Findings From the British Regional Heart Study

BACKGROUND AND PURPOSE

Research exploring the utility of cardiovascular health (CVH) and its Life's Simple 7 (LS7) components (body mass index, blood pressure [BP], glucose, cholesterol, physical activity, smoking, and diet) for prevention of stroke in older adults is limited. In the British Regional Heart Study, we explored (1) prospective associations of LS7 metrics and composite CVH scores with, and their impact on, stroke in middle and older age; and (2) if change in CVH was associated with subsequent stroke.

METHODS

Men without cardiovascular disease were followed from baseline recruitment (1978-1980), and again from re-examination 20 years later, for stroke over a median period of 20 years and 16 years, respectively. LS7 were measured at each time point except baseline diet. Cox models estimated hazard ratios (95% CI) of stroke for (1) ideal and intermediate versus poor levels of LS7; (2) composite CVH scores; and (3) 4 CVH trajectory groups (low-low, low-high, high-low, high-high) derived by dichotomising CVH scores from each time point across the median value. Population attributable fractions measured impact of LS7.

RESULTS

At baseline (n=7274, mean age 50 years), healthier levels of BP, physical activity, and smoking were associated with reduced stroke risk. At 20-year follow-up (n=3798, mean age 69 years) only BP displayed an association. Hazard ratios for intermediate and ideal (versus poor) levels of BP 0.65 (0.52-0.81) and 0.40 (0.24-0.65) at baseline; and 0.84 (0.67-1.05) and 0.57 (0.36-0.90) at 20-year follow-up. With reference to low-low trajectory, the low-high trajectory was associated with 40% reduced risk, hazard ratio 0.60 (0.44-0.83). Associations of CVH scores weakened, and population attributable fractions of LS7 reduced, from middle to old age; population attributable fraction of nonideal BP from 53% to 39%.

CONCLUSIONS

Except for BP, CVH is weakly associated with stroke at older ages. Prevention strategies for older adults should prioritize BP control but also enhance focus beyond traditional risk factors.

84 Circulating Vitamin D Levels and Frailty in the British Regional Heart Study: Cross Sectional and Prospective Associations

Introduction

Whether Vitamin D deficiency is linked to development of frailty, independent of other health conditions, is inconclusive. In the British Regional Heart Study we aimed to examine (1) cross sectional (CS) and prospective (PS) associations between Vitamin D levels and frailty; and (2) if these are mediated by conditions linked to low Vitamin D (diabetes, chronic obstructive pulmonary disease and inflammatory markers C-reactive protein & Interleukin-6).

Methods

Baseline (2010-2012) Vitamin D in men (71-92y) was categorised as deficiency (&lt;12 ng/ml), insufficiency (12 - &lt; 20 ng/ml) and sufficiency (≥20 ng/ml) states. Frailty, assessed at baseline and follow up (2014) was classified as robust, pre-frail or frail (score 0, 1-2, or ≥3 out of 5 Fried Frailty components respectively). Multinomial regression determined CS & PS relative risk ratios (RRR) of being pre-frail or frail, relative to robust. Adjustments were made for age, BMI, season, smoking, drinking habits, social class, Vitamin D/calcium supplements, mental/physical health and potential mediators.

Results

At baseline, 20% of 1494 men were frail and 25% deficient in Vitamin D. Unadjusted RRR of being frail (vs robust) was 3.16 [95% CI 2.16, 4.62] in men with Vitamin D&lt;12ng/ml (reference ≥20ng/ml). Higher RRR persisted even after adjusting for covariates and potential mediating factors, [2.74; 95% CI 1.60, 4.69]. Of 977 men non-frail at baseline, 10% became frail. Men with Vitamin D &lt;12ng/ml (reference ≥20ng/ml) had higher unadjusted RRR of becoming pre-frail [1.47; 95% CI 1.04, 2.09] and frail [2.14 95% CI 1.29, 3.56] (vs robust). While the PS association with pre-frailty was completely attenuated with covariate adjustment, higher RRR for frailty remained even in the fully adjusted model [2.07 95% CI 1.07, 4.00].

Conclusions

Vitamin D &lt;12ng/ml was associated with prevalent & incident frailty in older British men, independent of disease/inflammatory states. Further research exploring Vit D therapy for improving frailty outcomes is needed.

Reference

1. Parry SW. JAGS;2016;64(11):2368–2373.

Serum Conjugated Linoleic Acid and Risk of Incident Heart Failure in Older Men: The British Regional Heart Study

BACKGROUND

Evidence largely from animal studies suggests that conjugated linoleic acid (CLA) may have cardiovascular health benefits. However, few prospective studies have examined the association between CLA and cardiovascular disease. We have prospectively examined the association between serum CLA and incident coronary heart disease and heart failure (HF) in older men.

METHODS AND RESULTS

Prospective study of 3806 men, aged 60 to 79 years, without prevalent HF followed up for an average of 13 years, during which there were 295 incident HF cases. A high-throughput serum nuclear magnetic resonance metabolomics platform was used to measure CLA concentration in serum, expressed as a percentage of total fatty acids (CLA%). CLA% was adversely associated with cholesterol and high-density lipoprotein cholesterol but was inversely associated with C-reactive protein and NT-proBNP (N-terminal pro-B-type natriuretic peptide; a marker of ventricular stress). No association was seen between CLA% and incident coronary heart disease. High CLA% was associated with significantly reduced risk of HF after adjustment for HF risk factors and C-reactive protein (hazard ratio [95% confidence interval], 0.64 [0.43-0.96]; quartile 4 versus quartile 1). Elevated CLA% was associated with reduced HF risk only in those with higher dairy fat intake, a major dietary source of CLA (test for interaction P=0.03). The reduced risk of HF was partially explained by NT-proBNP. High dairy fat intake was not associated with incident coronary heart disease but was associated with reduced risk of HF, largely because of the inverse effect of CLA.

CONCLUSIONS

The finding that high CLA% is associated with lower risk of incident HF in older men requires confirmation in larger studies.

The effects of different alcoholic drinks on lipids, insulin and haemostatic and inflammatory markers in older men

Light to moderate drinking is associated with lower risk of coronary heart (CHD) than non-drinkers. We have examined the relationships between total alcohol intake and type of alcoholic beverage and several potential biological mechanisms.

We carried out the study in 3158 men aged 60-79 years drawn from general practices in 24 British towns with no history of myocardial infarction, stroke or diabetes and who were not on warfarin. Total alcohol consumption showed a significant positive dose-response relationship with high density lipoprotein cholesterol (HDL-C), coagulation factor IX, haematocrit, blood viscosity, and tissue plasminogen (t-PA) antigen, and an inverse dose-response relationship with insulin, fibrinogen, von Willebrand factor (vWF) and triglycerides after adjustment for possible confounders. Total alcohol consumption showed weak associations with plasma viscosity and fibrin D-dimer, and no association with factors VII, VIII, or C-reactive protein (CRP). Wine was specifically associated with lower CRP, plasma viscosity, factor VIII and triglycerides.

The findings are consistent with the suggestion that HDL-C in particular but also insulin and haemostatic factors may contribute to the beneficial effect of light to moderate drinking on risk of CHD.Wine has effects that may confer greater protection than other alcoholic beverages.

Serum uric acid as a potential marker for heart failure risk in men on antihypertensive treatment: The British Regional Heart Study

The role of serum uric acid (SUA) as a prognostic marker for incident heart failure (HF) in hypertensive subjects is uncertain. We have prospectively examined the relationship between SUA and incident HF in 3440 men aged 60–79 years separately in those on and not on antihypertensive treatment who were followed up for a mean period of 15 years. Men on SUA lowering drugs and those with history of HF or myocardial infarction were excluded. There were 260 incident HF cases. The men were divided into three groups of SUA concentrations/levels (< 350, 350–410 and > 410 μmol/L). Raised SUA was associated with significantly increased risk of HF in men on antihypertensive treatment (N = 949) but not in those without (N = 2491) (p = 0.003 for interaction). In men on antihypertensive treatment those with hyperuricemia (> 410 μmol/L) had the most adverse biological risk profile for HF including the highest rates of atrial fibrillation and renal dysfunction and the highest mean level of BMI, c-reactive protein and cardiac function (cardiac troponin T). Treated hypertensive men with SUA levels > 410 μmol/L showed an increase in risk of HF of more than twofold compared to those on treatment with levels < 350 μmol/L even after adjustment for lifestyle characteristics and biological risk factors [adjusted hazard ratio 2.26 (1.23,4.15)]. SUA improved prediction of HF beyond routine conventional risk factors (p = 0.02 for improvement in c-statistics). SUA as a marker of increased xanthine oxidase activity may be a useful prognostic marker for HF risk in older men on antihypertensive treatment.

•

Raised serum uric acid (SUA) is associated with increased risk of heart failure in older men on antihypertensive treatment

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Treated hypertensive men with raised SUA have the most adverse risk profile for heart failure including underlying ischaemia

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Monitoring of SUA in older hypertensive patients may identify high risk patients who would benefit from further investigation

Associations of time of day with cardiovascular disease risk factors measured in older men: results from the British Regional Heart Study

OBJECTIVE

We estimated associations of time of day with cardiovascular disease (CVD) risk factors measured in older men.

METHODS

CVD risk factors (markers of inflammation and haemostasis, and cardiac markers) were measured on one occasion between 08:00 and 19:00 hours in 4252 men aged 60-79 years from the British Regional Heart Study. Linear models were used to estimate associations between time of day and risk factors. When an association was found, we examined whether the relationship between risk factors and cardiovascular mortality was affected by the adjustment for time of day using survival analyses.

RESULTS

N-terminal pro-brain natriuretic peptide (NT-proBNP) levels increased by 3.3% per hour (95% CI 1.9% to 4.8%), interleukin-6 (IL-6) increased by 2.6% per hour (95% CI 1.8% to 3.4%), while tissue plasminogen activator (t-PA) decreased by 3.3% per hour (95% CI 3.7% to 2.9%); these associations were unaffected by adjustment for possible confounding factors. The percentages of variation in these risk factors attributable to time of day were less than 2%. In survival analyses, the association of IL-6, NT-proBNP and t-PA with cardiovascular mortality was not affected by the adjustment for time of day. C reactive protein, fibrinogen, D-dimer, von Willebrand factor and cardiac troponin T showed no associations with time of day.

CONCLUSIONS

In older men, markers of inflammation (IL-6), haemostasis (t-PA) and a cardiac marker (NT-proBNP) varied by time of day. The contribution of time of day to variations in these markers was small and did not appear to be relevant for the CVD risk prediction.

Association between physical activity levels in mid-life with physical activity in old age: a 20-year tracking study in a prospective cohort

OBJECTIVES

This study aims to examine the tracking and predictability of physical activity in old age from overall physical activity and participation in sport, recreational activity and walking in mid-life.

DESIGN

Prospective population-based cohort study.

SETTING

British Regional Heart Study participants recruited from primary care centres in the UK in 1978-1980.

PARTICIPANTS AND OUTCOME MEASURES

Men (n=3413) self-reported their physical activity at baseline, 12, 16 and 20-year follow-ups and were categorised as inactive or active and having high or low participation in sport, walking and recreational activities. Tracking was assessed using kappa statistics and random effects models. Logistic regression estimated the odds of being active at 20-year follow-up according to physical activity participation in mid-life.

RESULTS

Among 3413 men (mean age at baseline 48.6±5.4 years) with complete data, tracking of overall physical activity was moderate (kappa: 0.23-0.26). Tracking was higher for sports participation (kappa: 0.35-0.38) compared with recreational activity (kappa: 0.16-0.24) and walking (kappa: 0.11-0.15). Intraclass correlation coefficients demonstrated similar levels of stability and only marginally weakened after controlling for covariates. Compared with inactive men, being active at baseline was associated with greater odds of being active at 20-year follow-up (OR 2.7, 95% CI 2.4 to 3.2) after adjusting for sociodemographic, health and lifestyle variables. Playing sport in mid-life was more strongly associated with being active at 20-year follow-up than other domains, particularly when sport participation began earlier in life.

CONCLUSION

Being physically active in mid-life increases the odds of being active in old age. Promoting physical activity in later life might be best achieved by promoting sport participation earlier in the life course.

Self-reported sleep duration and napping, cardiac risk factors and markers of subclinical vascular disease: cross-sectional study in older men

STUDYOBJECTIVES

Daytime sleep has been associated with increased risk of cardiovascular disease and heart failure (HF), but the mechanisms remain unclear. We have investigated the association between daytime and night-time sleep patterns and cardiovascular risk markers in older adults including cardiac markers and subclinical markers of atherosclerosis (arterial stiffness and carotid intima-media thickness (CIMT)).

METHODS

Cross-sectional study of 1722 surviving men aged 71-92 examined in 2010-2012 across 24 British towns from a prospective study initiated in 1978-1980. Participants completed a questionnaire and were invited for a physical examination. Men with a history of heart attack or HF (n=251) were excluded from the analysis.

RESULTS

Self-reported daytime sleep duration was associated with higher fasting glucose and insulin levels (p=0.02 and p=0.01, respectively) even after adjustment for age, body mass index, physical activity and social class. Compared with those with no daytime sleep, men with daytime sleep >1 hour, defined as excessive daytime sleepiness (EDS), had a higher risk of raised N-terminal pro-brain natriuretic peptide of ≥400 pg/mL, the diagnostic threshold for HF (OR (95% CI)=1.88 (1.15 to 3.1)), higher mean troponin, reduced lung function (forced expiratory volume in 1 s) and elevated von Willebrand factor, a marker of endothelial dysfunction. However, EDS was unrelated to CIMT and arterial stiffness. By contrast, night-time sleep was only associated with HbA1c (short or long sleep) and arterial stiffness (short sleep).

CONCLUSIONS

Daytime sleep duration of >1 hour may be an early indicator of HF.

Associations between blood coagulation markers, NT-proBNP and risk of incident heart failure in older men: The British Regional Heart Study

AIMS

Chronic heart failure (HF) is associated with activation of blood coagulation but there is a lack of prospective studies on the association between coagulation markers and incident HF in general populations. We have examined the association between the coagulation markers fibrinogen, von Willebrand Factor (VWF), Factors VII, VIII and IX, D-dimer, activated protein C (APC) and activated partial thromboplastin time (aPPT) with NT-proBNP and incident HF.

METHODS AND RESULTS

Prospective study of 3366 men aged 60-79years with no prevalent HF, myocardial infarction or venous thrombosis and who were not on warfarin, followed up for a mean period of 13years, in whom there were 203 incident HF cases. D-dimer and vWF were significantly and positively associated with NT-proBNP (a marker of neurohormonal activation and left ventricular wall stress) even after adjustment for age, lifestyle characteristics, renal dysfunction, atrial fibrillation (AF) and inflammation (C-reactive protein). By contrast Factor VII related inversely to AF and NT-proBNP even after adjustment. No association was seen however between the coagulation markers VWF, Factor VII, Factor VIII, Factor IX, D-dimer, APC resistance or aPPT with incident HF in age-adjusted analyses. Fibrinogen was associated with incident HF but this was abolished after adjustment for HF risk factors.

CONCLUSION

Coagulation activity is not associated with the development of HF. However D-dimer and vWF were significantly associated with NT-proBNP, suggesting that increased coagulation activity is related to cardiac stress; and the increased coagulation seen in HF patients may in part be a consequence of neurohormonal activation.

Relationship between outdoor temperature and cardiovascular disease risk factors in older people

Background Previous studies demonstrated that lower outdoor temperatures increase the levels of established cardiovascular disease risk factors, such as blood pressure and lipids. Whether or not low temperatures increase novel cardiovascular disease risk factors levels is not well studied. The aim was to investigate associations of outdoor temperature with a comprehensive range of established and novel cardiovascular disease risk factors in two large Northern European studies of older adults, in whom cardiovascular disease risk is increased. Design and methods Data came from the British Regional Heart Study (4252 men aged 60-79 years) and the Prospective Study of Pravastatin in the Elderly at Risk (5804 men and women aged 70-82 years). Associations between outdoor temperature and cardiovascular disease risk factors were quantified in each study and then pooled using a random effects model. Results With a 5℃ lower mean temperature, total cholesterol was 0.04 mmol/l (95% confidence interval (CI) 0.02-0.07) higher, low density lipoprotein cholesterol was 0.02 mmol/l (95% CI 0.01-0.05) higher and SBP was 1.12 mm Hg (95% CI 0.60-1.64) higher. Among novel cardiovascular disease risk factors, C-reactive protein was 3.3% (95% CI 1.0-5.6%) higher, interleukin-6 was 2.7% (95% CI 1.1-4.3%) higher, and vitamin D was 11.2% (95% CI 1.0-20.4%) lower. Conclusions Lower outdoor temperature was associated with adverse effects on cholesterol, blood pressure, circulating inflammatory markers, and vitamin D in two older populations. Public health approaches to protect the elderly against low temperatures could help in reducing the levels of several cardiovascular disease risk factors.

Copeptin and the risk of incident stroke, CHD and cardiovascular mortality in older men with and without diabetes: The British Regional Heart Study

AIMS/HYPOTHESIS

This study aimed to examine the association between copeptin (a surrogate marker of arginine vasopressin) and incident stroke, CHD and cardiovascular mortality in older men with and without diabetes.

METHODS

We conducted a prospective study of 3536 men aged 60-79 years who were followed for an average of 13 years. During this period, there were 437 major CHD events (fatal and non-fatal myocardial infarction [MI]), 323 stroke events (fatal and non-fatal) and 497 cardiovascular disease (CVD) deaths. Prevalent diabetes was defined on the basis of a history of doctor-diagnosed diabetes or fasting blood glucose ≥7.0 mmol or HbA1c ≥6.5% (48 mmol/mol) (n = 428).

RESULTS

No association was seen between copeptin and incident stroke or CVD mortality in men without diabetes after adjustment for conventional cardiovascular risk factors, renal dysfunction, and insulin and N-terminal pro B-type natriuretic peptide levels. In contrast, elevated copeptin levels were associated with an increased risk of stroke and CVD mortality in men with diabetes after these adjustments. Compared with those in the lowest tertile of copeptin, men in the top tertile had adjusted relative HRs for stroke and CVD death of 2.34 (95% CI 1.04, 5.27) and 2.21 (1.12, 4.36), respectively. The risk of stroke and CVD mortality remained increased after the exclusion of men with prevalent stroke or MI. Higher levels of copeptin were associated with increased risk of CHD in the diabetic and non-diabetic groups, but these associations were attenuated after exclusion of individuals with a previous stroke or MI.

CONCLUSIONS/INTERPRETATION

Copeptin was independently associated with an increased risk of incident stroke and CVD mortality in men with diabetes, but not in men without diabetes. Targeting the arginine vasopressin system might have beneficial effects on CVD mortality and stroke risk in older men with diabetes.

Self-Reported Sleep Duration, Napping, and Incident Heart Failure: Prospective Associations in the British Regional Heart Study

Objectives

To examine the associations between self‐reported nighttime sleep duration and daytime sleep and incident heart failure (HF) in men with and without preexisting cardiovascular disease (CVD).

Design

Population‐based prospective study.

Setting

General practices in 24 British towns.

Participants

Men aged 60–79 without prevalent HF followed for 9 years (N = 3,723).

Measurements

Information on incident HF cases was obtained from primary care records. Assessment of sleep was based on self‐reported sleep duration at night and daytime napping.

Results

Self‐reported short nighttime sleep duration and daytime sleep of longer than 1 hour were associated with preexisting CVD, breathlessness, depression, poor health, physical inactivity, and manual social class. In all men, self‐reported daytime sleep of longer than 1 hour duration was associated with significantly greater risk of HF after adjustment for potential confounders (adjusted hazard ratio (aHR) = 1.69, 95% CI = 1.06–2.71) than in those who reported no daytime napping. Self‐reported nighttime sleep duration was not associated with HF risk except in men with preexisting CVD (<6 hours: aHR = 2.91, 95% CI = 1.31–6.45; 6 hours: aHR = 1.89, 95% CI = 0.89–4.03; 8 hours: aHR = 1.29, 95% CI = 0.61–2.71; ≥9 hours: aHR = 1.80, 905% CI = 0.71–4.61 vs nighttime sleep of 7 hours). Snoring was not associated with HF risk.

Conclusion

Self‐reported daytime napping of longer than 1 hour is associated with greater risk of HF in older men. Self‐reported short sleep (<6 hours) in men with CVD is associated with particularly high risk of developing HF.

Effect of cold spells and their modifiers on cardiovascular disease events: Evidence from two prospective studies

OBJECTIVE

To investigate effects of cold weather spells on incidence of cardiovascular disease (CVD), and potential effect modification of socio-demographic, clinical, behavioural and environmental exposures.

METHODS

Data from two prospective studies were analysed: the British Regional Heart Study (BRHS), a population-based study of British men aged 60-79years, followed for CVD incidence from 1998-2000 to 2012; and the PROSPER study of men and women aged 70-82 recruited to a trial of pravastatin vs placebo from 1997 to 9 (followed until 2009). Cold spells were defined as at least three consecutive days when daily mean temperature fell below the monthly 10th percentile specific to the closest local weather station. A time-stratified case-crossover approach was used to estimate associations between cold spells and CVD events.

RESULTS

921 of 4252 men from BRHS and 760 of 2519 participants from PROSPER suffered a first CVD event during follow-up. More CVD events were registered in winter in both studies. The risk ratio (RR) associated with cold spells was statistically significant in BRHS (RR=1.86, 95% CI 1.30-2.65, p<0.001), and independent of temperature level: results were similar whether events were fatal or non-fatal. Increased risk was particularly marked in BRHS for ever-smokers (RR of 2.44 vs 0.99 for never-smokers), in moderate/heavy drinkers (RR 2.59 vs 1.41), and during winter months (RR 3.28 vs 1.25). No increased risk was found in PROSPER.

CONCLUSIONS

Although CVD risks were higher in winter in both BRHS and PROSPER prospective studies, cold spells increased risk of CVD events, independently of cold temperature, in the BRHS only.

Lung function and airway obstruction: associations with circulating markers of cardiac function and incident heart failure in older men-the British Regional Heart Study

Aims

The association between lung function and cardiac markers and heart failure (HF) has been little studied in the general older population. We have examined the association between lung function and airway obstruction with cardiac markers N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT) and risk of incident HF in older men.

Methods and results

Prospective study of 3242 men aged 60–79 years without prevalent HF or myocardial infarction followed up for an average period of 13 years, in whom 211 incident HF cases occurred. Incident HF was examined in relation to % predicted FEV1 and FVC. The Global Initiative on Obstructive Lung Diseases spirometry criteria were used to define airway obstruction. Reduced FEV1, but not FVC in the normal range, was significantly associated with increased risk of HF after adjustment for established HF risk factors including inflammation. The adjusted HRs comparing men in the 6–24th percentile with the highest quartile were 1.91 (1.24 to 2.94) and 1.30 (0.86 to 1.96) for FEV1 and FVC, respectively. FEV1 and FVC were inversely associated with NT-proBNP and cTnT, although the association between FEV1 and incident HF remained after adjustment for NT-proBNP and cTnT. Compared with normal subjects (FEV1/FVC ≥0.70 and FVC≥80%), moderate or severe (FEV1/FVC <0.70 and FEV1 <80%) airflow obstruction was independently associated with HF ((adjusted relative risk 1.59 (1.08 to 2.33)). Airflow restriction (FEV1/FVC ≥0.70 and FVC <80%) was not independently associated with HF.

Conclusions

Reduced FEV1 reflecting airflow obstruction is associated with cardiac dysfunction and increased risk of incident HF in older men.

Mild hyponatremia, hypernatremia and incident cardiovascular disease and mortality in older men: A population-based cohort study

AIM

To examine the association between serum sodium concentration and incident major cardiovascular disease (CVD) outcomes and total mortality in older men.

METHODS AND RESULTS

A prospective study of 3099 men aged 60-79 years without a history of cardiovascular disease followed up for an average 11 years during which there were 528 major CVD events (fatal coronary heart disease [CHD] and non-fatal MI, stroke and CVD death) and 873 total deaths. A U shaped relationship was seen between serum sodium concentration and major CVD events and mortality. Hyponatremia (<136 mEq/L) and low sodium within the normal range (136-138 mEq/L) showed significantly increased risk of major CVD events and total mortality compared to men within the upper normal range (139-143 mEq/L) after adjustment for a wide range of confounders and traditional risk factors [adjusted HRs 1.55 (1.13,2.12) and 1.40 (1.14,1.72) for major CVD events respectively and 1.30 (1.02,1.66) and 1.30 (1.11,1.53) respectively for total mortality]. Hyponatremia was associated with inflammation, NT-proBNP, low muscle mass and alkaline phosphatase; these factors contributed to the increased total mortality associated with hyponatremia but did not explain the increased risk of CVD events associated with hyponatremia or low normal sodium concentration. Hypernatremia (≥145 mEq/L) was associated with significantly increased risk of CVD events and mortality due to CVD causes.

CONCLUSION

Mild hyponatremia even within the normal sodium range and hypernatremia are both associated with increased total mortality and major CVD events in older men without CVD which is not explained by known adverse CV risk factors.

Body mass index in early and middle adult life: prospective associations with myocardial infarction, stroke and diabetes over a 30-year period: the British Regional Heart Study

OBJECTIVES

Adiposity in middle age is an established risk factor for cardiovascular disease and type 2 diabetes; less is known about the impact of adiposity from early adult life. We examined the effects of high body mass index (BMI) in early and middle adulthood on myocardial infarction (MI), stroke and diabetes risks.

DESIGN

A prospective cohort study.

PARTICIPANTS

7735 men with BMI measured in middle age (40-59 years) and BMI ascertained at 21 years from military records or participant recall.

PRIMARY AND SECONDARY OUTCOME MEASURES

30-year follow-up data for type 2 diabetes, MI and stroke incidence; Cox proportional hazards models were used to examine the effect of BMI at both ages on these outcomes, adjusted for age and smoking status.

RESULTS

Among 4846 (63%) men (with complete data), a 1 kg/m(2) higher BMI at 21 years was associated with a 6% (95% CI 4% to 9%) higher type 2 diabetes risk, compared with a 21% (95% CI 18% to 24%) higher diabetes risk for a 1 kg/m(2) higher BMI in middle age (hazard ratio (HR) 1.21, 95% CI 1.18 to 1.24). Higher BMI in middle age was associated with a 6% (95% CI 4% to 8%) increase in MI and a 4% (95% CI 1% to 7%) increase in stroke; BMI at 21 years showed no associations with MI or stroke risk.

CONCLUSIONS

Higher BMI at 21 years of age is associated with later diabetes incidence but not MI or stroke, while higher BMI in middle age is strongly associated with all outcomes. Early obesity prevention may reduce later type 2 diabetes risk, more than MI and stroke.

Copeptin, Insulin Resistance, and Risk of Incident Diabetes in Older Men

CONTEXT

Prior studies suggested a role for the arginine vasopressin (AVP) system in the pathogenesis of diabetes. Prospective studies on the association between copeptin (the C-terminal fragment of AVP hormone) and incident diabetes are limited.

OBJECTIVE

We have examined the association between plasma copeptin and the risk of incident diabetes in older men.

DESIGN

The British Regional Heart Study was a prospective study with an average of 13 years follow-up.

SETTING

General practices in the United Kingdom were studied.

PARTICIPANTS

Participants were 3226 men aged 60 to 79 years with no prevalent diabetes.

OUTCOME

We measured 253 patients with incident diabetes.

RESULTS

Copeptin was positively and significantly associated with renal dysfunction, insulin resistance (homeostasis model assessment of insulin resistance), metabolic risk factors (waist circumference, blood pressure, triglycerides, and liver function), C-reactive protein, tissue plasminogen activator, and von Willebrand factor (endothelial dysfunction) but not with plasma glucose. The risk of incident diabetes was significantly elevated only in men in the top fifth of the copeptin distribution (>6.79 pmol/L), and this risk persisted after adjustment for several diabetes risk factors including metabolic risk factors and C-reactive protein (adjusted hazard ratio in the top fifth vs the rest = 1.78 [95% confidence interval, 1.34-2.37]). Risk was markedly attenuated although it remained significant after further adjustment for homeostasis model assessment of insulin resistance and plasma glucose (adjusted hazard ratio = 1.47 [1.11-1.97]). The increased risk was seen even when the analysis was restricted to men with no chronic kidney disease or to men with no impaired fasting glucose (<6.1 mmol/L).

CONCLUSION

Copeptin is associated with a significantly increased risk of diabetes in older men. The association is partly mediated through lower insulin sensitivity. The findings suggest a potential role of the AVP system in diabetes.

Alcohol consumption and risk of incident heart failure in older men: a prospective cohort study

Aims

Light-to-moderate drinking has been associated with reduced risk of heart failure (HF). We have examined the association between alcohol consumption and incident HF in older British men.

Methods and results

Prospective study of 3530 men aged 60–79 years with no diagnosed HF or myocardial infarction (MI) at baseline and followed up for a mean period of 11 years, in whom there were 198 incident HF cases. Men were divided into 6 categories of alcohol consumption: none, <1, 1–6, 7–13, 14–34 and ≥35 drinks/week. There was no evidence that light-to-moderate drinking is beneficial for risk of HF. Heavy drinking (≥35 drinks/week) was associated with significantly increased risk of HF. Using the large group of men drinking 1–6 drinks/week as the reference group, the relative HRs (95% confidence interval) for HF adjusted for age, lifestyle characteristics, blood pressure, atrial fibrillation and renal dysfunction were 0.97 (0.59 to 1.63), 1.39 (0.86 to 2.25), 1.00, 0.94 (0.64 to 1.43), 1.16 (0.78 to 1.71) and 1.91 (1.02 to 3.56) for the 6 alcohol groups, respectively. The increased risk associated with heavy drinking was attenuated after adjustment for N-terminal pro-brain natriuretic peptide (NT-proBNP) (HR=1.43 (0.76 to 1.69)). Stratified analysis showed heavy drinking was associated with increased HF risk only in those with ECG evidence of myocardial ischaemia.

Conclusions

There was no evidence that light-to-moderate drinking is beneficial for the prevention of HF in older men without a history of an MI. Heavier drinking (≥5 drinks/day), however, was associated with increased risk of HF in vulnerable men with underlying myocardial ischaemia.

Diurnal patterns of objectively measured physical activity and sedentary behaviour in older men

BACKGROUND

Physical activity (PA) levels among older adults are generally low and sedentary behaviour (SB) very common; increasing PA and reducing SB levels could have appreciable health benefits. Quantifying PA and SB patterns through the day could help in defining strategies for change. We examined within day variations in PA and SB and whether these varied by demographic factors and health status.

METHODS

Men aged 71-91 years participating in an established UK population-based cohort study were invited to wear a GT3x Actigraph accelerometer over the hip for one week in 2010-12. Percentages of time spent in sedentary (SB, <100 counts per minute [CPM]); in light (LIPA, 100-1040 CPM) and in moderate to vigorous PA (MVPA, >1040 CPM) were derived. Multilevel models were used to estimate the associations between demographic factors and health status and SB, LIPA and MVPA.

RESULTS

1455 of 3137 men invited (46.4 %) participated and provided adequate data. Men spent 73 % of the day in SB, 23 % in LIPA and 4.5 % in MVPA (619, 197 and 39 min per day respectively). The percentage of time spent in MVPA was highest in the morning, peaking at 10-11 am (8.4 %), and then declining until the evening, with the exception of a small increase at 2-3 pm. LIPA followed a similar pattern. Conversely, SB levels were lowest in the morning and increased throughout the day, peaking at 9 pm (88 %). Men who were older, did not use active transport, had mobility limitations, were obese, depressed, had more chronic health conditions, and were smokers had lower levels of MVPA. The impacts of older age, obesity, mobility limitations and chronic diseases on LIPA, MVPA and SB were more marked in the morning than in the afternoon and evening.

CONCLUSIONS

Levels of MVPA and LIPA are highest in the morning (peak at 10-11 am) and decrease during the day. SB increases through the course of the day to peak in the evening. Interventions to encourage older men to be physically active may need to take account of current PA patterns, aiming to prolong active morning bouts of PA and/or reducing SB in the afternoon and evening hours.

Associations between fibrin D-dimer, markers of inflammation, incident self-reported mobility limitation, and all-cause mortality in older men

OBJECTIVES

To examine the independent relationships between fibrin D-dimer, interleukin 6 (IL-6), C-reactive protein (CRP), and fibrinogen and incident mobility limitation and mortality.

DESIGN

Prospective.

SETTING

General practice in 24 British towns.

PARTICIPANTS

Men aged 60 to 79 without prevalent heart failure followed up for an average of 11.5 years (N = 3,925).

MEASUREMENTS

All-cause mortality (n = 1,286) and self-reported mobility disability obtained at examination in 1998 to 2000 and in a postal questionnaire 3 to 5 years later in 2003.

RESULTS

High D-dimer (top vs lowest tertile: adjusted odds ratio (aOR) = 1.46, 95% confidence interval = 1.02-2.05) and IL-6 (aOR = 1.43, 95% CI = 1.01-2.02) levels (but not CRP or fibrinogen) were associated with greater incident mobility limitation after adjustment for confounders and prevalent disease status. IL-6, CRP, fibrinogen, and D-dimer were significantly associated with total mortality after adjustment for confounders. Only D-dimer and IL-6 predicted total mortality independent of each other and the other biomarkers. The adjusted hazard ratio (aHR) was 1.16 (95% CI = 1.10-1.22) for a standard deviation increase in log D-dimer and 1.10 (95% CI = 1.04-1.18) for a standard deviation increase in log IL-6. D-dimer was independently related to vascular and nonvascular mortality, and IL-6 was independently related to vascular mortality. Risks of mobility limitation and mortality were greatest in those with a combination of high D-dimer and IL-6 levels.

CONCLUSION

D-dimer and IL-6 are associated with risk of mobility limitation and mortality in older men without heart failure. The findings suggest that coagulation leads to functional decline and mortality s that inflammation does not explain.

Elevated parathyroid hormone, but not vitamin D deficiency, is associated with increased risk of heart failure in older men with and without cardiovascular disease

BACKGROUND

Hyperparathyroidism and low vitamin D status have been implicated in the pathogenesis of heart failure (HF). We examined the prospective associations between parathyroid hormone (PTH), circulating 25-hydroxyvitamin D, and markers of mineral metabolism and risk of incident HF in older men with and without established cardiovascular disease.

METHODS AND RESULTS

Prospective study of 3731 men aged 60 to 79 years with no prevalent HF followed up for a mean period of 13 years, in whom there were 287 incident HF cases. Elevated PTH (≥55.6 pg/mL; top quarter) was associated with significantly higher risk of incident HF after adjustment for lifestyle characteristics, diabetes mellitus, blood lipids, blood pressure, lung function, heart rate, renal dysfunction, atrial fibrillation, forced expiratory volume in 1 second, and C-reactive protein (hazards ratio, 1.66; 95% confidence interval, 1.30-2.13). The increased risk was seen in both men with and without previous myocardial infarction or stroke (hazards ratio, 1.72; 95% confidence interval, 1.07-2.76; hazards ratio, 1.70; 95% confidence interval, 1.25-2.30, respectively). Elevated PTH was significantly associated with N-terminal probrain natriuretic peptide, a marker of left ventricular wall stress. By contrast, 25-hydroxyvitamin D and other markers of mineral metabolism including serum calcium and phosphate showed no significant association with incident HF after adjustment for age.

CONCLUSIONS

Elevated PTH, but not 25-hydroxyvitamin D or other markers of mineral metabolism, is associated with increased risk of HF in both older men with and without myocardial infarction/stroke. This increased risk was not explained by its association with known risk factors for HF. Further studies are now needed to elucidate the mechanisms underlying this association.

Plasma vitamin C, but not vitamin E, is associated with reduced risk of heart failure in older men

BACKGROUND

Oxidative stress has been implicated in the pathogenesis of heart failure (HF). However, data on the association between antioxidant intakes and circulating levels and risk of incident HF in the older general population are limited. We have examined prospectively the associations between plasma vitamin C and E, dietary intakes of vitamin C and E, and incident HF.

METHODS AND RESULTS

Prospective study of 3919 men aged 60 to 79 years with no prevalent HF followed up for a mean period of 11 years, in whom there were 263 cases with incident HF. Higher plasma vitamin C level was associated with significantly lower risk of incident HF in both men with and without previous myocardial infarction after adjustment for lifestyle characteristics, diabetes mellitus, blood lipids, blood pressure, and heart rate (hazards ratio [95% confidence interval], 0.81 [0.70, 0.93] and 0.75 [0.59, 0.97] for 1 SD increase in log vitamin C, respectively). Plasma vitamin E and dietary vitamin C intake showed no association with HF. High levels of dietary vitamin E intake (which correlated weakly with plasma vitamin E) were associated with increased risk of HF in men with no previous myocardial infarction even after adjustment (adjusted hazards ratio [95% confidence interval], 1.23 [1.06, 1.42] for 1 SD increase).

CONCLUSIONS

Higher plasma vitamin C is associated with a reduced risk of HF in older men with and without myocardial infarction. High intake of dietary vitamin E may be associated with increased HF risk. Primary intervention trials assessing the effect of vitamin C supplements on HF risk in the elderly are needed.

Alkaline Phosphatase, Serum Phosphate, and Incident Cardiovascular Disease and Total Mortality in Older Men

Objective—

We have examined the association between serum phosphate and alkaline phosphatase (ALP) with incident cardiovascular disease (CVD) outcomes and total mortality in older men.

Approach and Results—

A prospective study of 3381 men, aged 60 to 79 years, without a history of myocardial infarction or stroke followed up for an average 11 years during which there were 605 major CVD events (fatal coronary heart disease and nonfatal myocardial infarction, stroke, and CVD death) and 984 total deaths. ALP but not serum phosphate was associated with increased risk of coronary heart disease and overall CVD events which persisted after adjustment for CVD risk factors and markers of inflammation and after exclusion of men with chronic kidney disease (adjusted hazard ratio per SD, 1.19 [1.05, 1.34]; P =0.007 and 1.10 [1.01, 1.21]; P =0.04). In contrast, serum phosphate was only associated with increased CVD mortality owing to noncoronary heart disease or stroke causes (adjusted hazard ratio per SD, 1.35 [1.01, 1.83]; P =0.04). Both raised phosphate and ALP were associated with significantly increased total mortality after full adjustment and exclusion of men with chronic kidney disease.

Conclusions—

ALP but not serum phosphate is associated with coronary heart disease risk in elderly men. High levels of ALP and serum phosphate are both associated with increased total mortality.

Adiposity, adipokines, and risk of incident stroke in older men

BACKGROUND AND PURPOSE

The association between adiposity and adipocytes and risk of stroke in older adults is uncertain. We have examined the association between adiposity measures and adipocytes (adiponectin and leptin) with incident stroke events in older men.

METHODS

Prospective study of 3411 men aged 60 to 79 years with no previous diagnosis of myocardial infarction, heart failure, or stroke followed-up for an average of 9 years, during which there were 192 incident major stroke events.

RESULTS

In age-adjusted analyses, body mass index and waist circumference were not significantly associated with risk of stroke in older men, although obese men (body mass index >30 kg/m(2)) showed the lowest risk of stroke. Despite the strong positive correlation between leptin and body mass index and waist circumference, risk of stroke was significantly increased in those in the top quartile of the leptin distribution. The increased risk remained after adjustment for potential confounders, including systolic blood pressure (adjusted hazard ratios top quartile versus bottom quartile: 2.03; confidence interval, 1.27-3.27]). Further adjustment for markers of inflammation (c-reactive protein), endothelial dysfunction (von Willebrand factor), fibrinolytic activity (d-dimer), and γ-glutamyl transferase attenuated the increased risk, but risk remained significantly increased (adjusted hazard ratios, 1.73; confidence interval, 1.06-2.83]). By contrast, no association was seen between adiponectin and risk of stroke.

CONCLUSIONS

Conventional adiposity measures were not associated with increased stroke risk in older men. However, leptin (a good marker of percent fat mass), but not adiponectin, predicted stroke, suggesting a link between fat mass and stroke risk.

Longitudinal associations between changes in physical activity and onset of type 2 diabetes in older British men: the influence of adiposity

OBJECTIVE

To determine how much physical activity (PA) is needed to protect against diabetes onset in older adults, whether protection is greater among overweight individuals, and whether taking up moderate activity in later life is beneficial.

RESEARCH DESIGN AND METHODS

Men (4,252) from a U.K. population-based cohort self-reported usual PA (regular walking and cycling, recreational activity, and sport) in 1996 and in 1998-2000, alongside other health behaviors and medical history. Fasting blood lipids were measured. Median follow-up was 7.1 years, during which 135 cases of type 2 diabetes (validated self-report) occurred.

RESULTS

Among 3,012 men free from cardiovascular disease and diabetes in 1998-2000, 9% reported no usual leisure-time PA, 23% occasional PA, and 15% vigorous PA. Compared with men reporting no activity, men reporting occasional, light, moderate, moderately vigorous, and vigorous PA had lower diabetes risks: hazard ratio (HR) 0.58 (95% CI 0.33-1.02), 0.39 (0.20-0.74), 0.38 (0.19-0.73), 0.39 (0.20-0.77), and 0.33 (0.16-0.70), respectively; P (trend) = 0.002, adjusted for age, social class, tobacco, alcohol, diet, and blood lipids. Adjustment for BMI, waist circumference, or fasting insulin attenuated HRs. HRs were stronger in men with BMI ≥28 vs. <28 kg/m(2) (interaction P = 0.02). Compared with men reporting light activity or less in 1996 and 2000, men who became at least moderately active by 2000 or remained at least moderately active at both times had adjusted HRs of 0.62 (0.34-1.12) and 0.51 (0.31-0.82), respectively.

CONCLUSIONS

Even light PA markedly reduced diabetes risk in older men, especially among the overweight or obese. Taking up or maintaining at least moderate PA in older adulthood strongly protected against diabetes.

Fibrin D-dimer, tissue-type plasminogen activator, von Willebrand factor, and risk of incident stroke in older men

BACKGROUND AND PURPOSE

Abnormalities in blood coagulation and the fibrinolytic system have been associated with increased risk of stroke, but few prospective studies have studied the associations in older adults. We have examined the associations between fibrin D-dimer, tissue-type plasminogen activator, and von Willebrand factor (vWF) and risk of stroke in older men and examined their predictive roles separately in normotensive and hypertensive men.

METHODS

Prospective study of 3358 men aged 60 to 79 years with no previous diagnosis of myocardial infarction or stroke and without atrial fibrillation followed-up for an average of 9 years, during which there were 187 incident stroke events.

RESULTS

Increased levels of D-dimer and vWF were associated with significantly increased risk of major stroke events after adjustment for potential confounders, including systolic blood pressure (adjusted hazard ratios and 95% confidence interval per standard deviation increase in D-dimer and vWF were 1.24 [95% confidence interval, 1.08-1.44] and 1.25 [95% confidence interval, 1.09-1.45], respectively). No associations were seen with tPA after adjustment. The positive associations between D-dimer and vWF and incident stroke remained after additional adjustment for markers of inflammation (C-reactive protein, IL-6). D-dimer was associated with stroke in both normotensive and hypertensive men; vWF showed stronger associations in normotensive than in hypertensive men (test for interaction: P=0.52 for D-dimer; P<0.01 for vWF).

CONCLUSIONS

Fibrin D-dimer and vWF are associated with increased risk of stroke in older men. These associations were not explained by their associations with inflammation. D-dimer may be a useful marker to identify those at high risk for stroke among hypertensive men.

Γ-glutamyltransferase, hepatic enzymes, and risk of incident heart failure in older men

OBJECTIVE

The relationship between γ-glutamyl transferase (GGT) and heart failure (HF) in older adults is unknown. We have examined the relationship between GGT, other markers of hepatic function (alanine aminotransferase, aspartate transaminase, and alkaline phosphatase), and incident HF in older men.

METHODS AND RESULTS

This was a prospective study of 3494 men aged 60 to 79 years with no diagnosed HF or myocardial infarction followed up for a mean period of 9 years, in whom there were 168 incident HF cases. Elevated GGT (top quartile, ≥38 U/L) was associated with significantly increased risk of incident HF in men aged<70 years but not in men aged≥70 years (test for age-GGT interaction, P<0.0001). The increased risk of HF associated with elevated GGT persisted after adjustment for a wide range of established and novel risk factors for HF, including diabetes, stroke, obesity, systolic blood pressure, atrial fibrillation, lung function, inflammation (C-reactive protein), endothelial dysfunction (von Willebrand factor), leptin, and N terminal pro brain natriuretic peptide (adjusted hazard ratio [95% CI], 1.91 [1.07, 3.42]). Other liver function markers showed no significant associations with HF after similar adjustments.

CONCLUSION

Elevated GGT was associated with increased risk of HF in men aged<70 years. Additional studies are now needed to determine the mechanisms responsible.

Obesity and risk of incident heart failure in older men with and without pre-existing coronary heart disease: does leptin have a role?

OBJECTIVES

We examined the relationship between body mass index (BMI), waist circumference, and incident HF in men with and without pre-existing coronary heart disease (CHD) and assessed the contribution of plasma leptin concentration to these associations.

BACKGROUND

Leptin has been proposed as a potential link between obesity and heart failure (HF).

METHODS

This was a prospective study of 4,080 men age 60 to 79 years with no diagnosed HF followed for a mean period of 9 years, in whom there were 228 incident HF cases.

RESULTS

Increased BMI was associated with significantly increased risk of HF in men with and without pre-existing CHD (myocardial infarction or angina) after adjustment for cardiovascular risk factors including C-reactive protein. The adjusted hazard ratios (HRs) associated with a 1-SD increase in BMI were 1.37 (95% confidence interval [CI]: 1.09 to 1.72) and 1.18 (95% CI: 1.00 to 1.39) in men with and without CHD, respectively. Increased leptin was significantly associated with an increased risk of HF in men without pre-existing CHD, independent of BMI and potential mediators (adjusted HR for a 1-SD increase in log leptin: 1.30 [95% CI: 1.06 to 1.61]; p = 0.01). However, no association was seen in those with pre-existing CHD (corresponding HR: 1.06 [95% CI: 0.77 to 1.45]; p = 0.72). Adjustment for leptin abolished the association between BMI and HF in men with no CHD; in those with CHD, the association between BMI and HF remained significant (p = 0.03). Similar patterns were seen for waist circumference.

CONCLUSIONS

In the absence of established CHD, the association between obesity and HF may be mediated by plasma leptin. In those with CHD, obesity appears to increase the risk of HF independent of leptin.

N-terminal pro-brain natriuretic Peptide is a more useful predictor of cardiovascular disease risk than C-reactive protein in older men with and without pre-existing cardiovascular disease

OBJECTIVES

We aimed to compare the predictive capabilities of N-terminal pro-brain natriuretic peptide (NT-proBNP) and C-reactive protein (CRP) for risk of cardiovascular disease (CVD) in older men with and without pre-existing CVD.

BACKGROUND

The clinical utility of NT-proBNP in CVD risk stratification in the general population remains unclear.

METHODS

A prospective study of 3,649 men age 60 to 79 years were followed for a mean of 9 years during which there were 608 major CVD events (major fatal and nonfatal coronary heart disease, stroke, and CVD death).

RESULTS

NT-proBNP was significantly associated with risk of all major CVD outcomes after adjustment for CV risk factors in both men with and without CVD. The adjusted standardized hazard ratios for CVD events in those without pre-existing CVD and those with pre-existing CVD were 1.49 (95% confidence interval [CI]: 1.33 to 1.65) and 1.52 (95% CI: 1.33 to 1.75), respectively. CRP was associated with CVD outcomes only in men without pre-existing CVD (adjusted standardized hazard ratios: 1.22 [95% CI: 1.10 to 1.34] and 1.00 [95% CI: 0.86 to 1.38], respectively). NT-proBNP was more strongly associated with CVD outcome than CRP, particularly among those with pre-existing CVD. Inclusion of NT-proBNP in a Framingham-based model yielded significant improvement in C-statistics in both men with and without CVD and resulted in a net reclassification improvement of 8.8% (p = 0.0009) and 8.2% (p < 0.05), respectively, for major CVD events. Inclusion of CRP in the Framingham-based model did not improve prediction in either group (net reclassification improvement 3.8% and 0.6%, respectively).

CONCLUSIONS

NT-proBNP, but not CRP, improved prediction of major CVD events in older men with and without pre-existing CVD.

Socioeconomic inequalities in coronary heart disease risk in older age: contribution of established and novel coronary risk factors

BACKGROUND

Evidence on socioeconomic inequalities in coronary heart disease (CHD) and their pathways in the elderly is limited. Little is also known about the contributions that novel coronary risk factors (particularly inflammatory/hemostatic markers) make to socioeconomic inequalities in CHD.

OBJECTIVES

To examine the extent of socioeconomic inequalities in CHD in older age, and the contributions (relative and absolute) of established and novel coronary risk factors.

METHODS

A population-based cohort of 3761 British men aged 60-79 years was followed up for 6.5 years for CHD mortality and incidence (fatal and non-fatal). Social class was based on longest-held occupation recorded at 40-59 years.

RESULTS

There was a graded relationship between social class and CHD incidence. The hazard ratio for CHD incidence comparing social class V (unskilled workers) with social class I (professionals) was 2.70 [95% confidence interval (CI) 1.37-5.35; P-value for trend = 0.008]. This was reduced to 2.14 (95% CI 1.06-4.33; P-value for trend = 0.11) after adjustment for behavioral factors (cigarette smoking, physical activity, body mass index, and alcohol consumption), which explained 38% of the relative risk gradient (41% of absolute risk). Additional adjustment for inflammatory markers (C-reactive protein, interleukin-6, and von Willebrand factor) explained 55% of the relative risk gradient (59% of absolute risk). Blood pressure and lipids made little difference to these estimates; results were similar for CHD mortality.

CONCLUSIONS

Socioeconomic inequalities in CHD persist in the elderly and are at least partly explained by behavioral risk factors; novel (inflammatory) coronary risk markers made some further contribution. Reducing inequalities in behavioral factors (especially cigarette smoking) could reduce these social inequalities by at least one-third.

Circulating inflammatory and hemostatic biomarkers are associated with risk of myocardial infarction and coronary death, but not angina pectoris, in older men

AIMS

The extent to which hemostatic and inflammatory biomarkers are related to angina pectoris as compared with myocardial infarction (MI) remains uncertain. We examined the relationship between a wide range of inflammatory and hemostatic biomarkers, including markers of activated coagulation, fibrinolysis and endothelial dysfunction and viscosity, with incident myocardial infarction (MI) or coronary heart disease (CHD) death and incident angina pectoris uncomplicated by MI or CHD death in older men.

METHODS

A prospective study of 3217 men aged 60-79 years with no baseline CHD (angina or MI) and who were not on warfarin, followed up for 7 years during which there were 198 MI/CHD death cases and 220 incident uncomplicated angina cases.

RESULTS

Inflammatory biomarkers [C-reactive protein (CRP), interleukin-6, fibrinogen], plasma viscosity and hemostatic biomarkers [von Willebrand factor (VWF) and fibrin D-dimer] were associated with a significant increased risk of MI/CHD death but not with uncomplicated angina even after adjustment for age and conventional risk factors. Adjustment for CRP attenuated the relationships between VWF, fibrin D-dimer and plasma viscosity with MI/CHD death. Comparisons of differing associations with risk of MI/CHD deaths and uncomplicated angina were significant for the inflammatory markers (P < 0.05) and marginally significant for fibrin D-dimer (P = 0.05). In contrast, established risk factors including blood pressure and high-density lipoprotein (HDL)-cholesterol were associated with both MI/CHD death and uncomplicated angina.

CONCLUSION

Circulating biomarkers of inflammation and hemostasis are associated with incident MI/CHD death but not incident angina uncomplicated by MI or CHD death in older men.

Prospective study of matrix metalloproteinase-9 and risk of myocardial infarction and stroke in older men and women

OBJECTIVES

The endopeptidase matrix metalloproteinase-9 (MMP-9) is implicated in atherosclerotic plaque rupture. We investigate prospective associations between MMP-9 and MI or stroke in an older general population cohort, accounting for established and novel cardiovascular risk factors.

METHODS

Baseline serum MMP-9 was measured in incident MI (n=368) and stroke (n=299) cases and two controls per case, 'nested' in prospective studies of 4252 men and 4286 women aged 60-79 years, sampled from General Practices in Britain in 1998-2000, with 7-year follow-up for fatal and non-fatal MI and stroke.

RESULTS

Geometric mean MMP-9 was 528 ng/mL (IQR 397, 743) in MI cases compared to 501 ng/mL (IQR 370, 743) in controls, p=0.10. Participants in the top compared to bottom third of MMP-9 levels had an age-adjusted odds ratio for MI of 1.53 (95% CI 1.09, 2.13), which attenuated to 1.18 (95% CI 0.81, 1.70) after adjustment for established and novel cardiovascular risk factors. There was weak evidence that OR differed according to pre-existing CVD; the OR for MI in 187 participants with pre-existing CVD was 2.20 (1.04, 4.64) and 1.24 (0.84, 1.82) in 715 participants without (LR test for interaction p=0.06). Geometric mean MMP-9 levels were higher in stroke cases than controls; 522ng/mL (IQR 363, 673) vs 487 (IQR 393, 704), p=0.045; however adjustments similarly attenuated the associations.

CONCLUSIONS

While serum MMP-9 is univariately associated with risk of MI and stroke, it is not a strong independent risk marker for either.

Is socioeconomic position related to the prevalence of metabolic syndrome?: influence of social class across the life course in a population-based study of older men

OBJECTIVE

To examine whether adult social class and childhood social class are related to metabolic syndrome in later life, independent of adult behavioral factors.

RESEARCH DESIGN AND METHODS

This was a population-based cross-sectional study comprising 2,968 men aged 60-79 years.

RESULTS

Adult social class and childhood social class were both inversely related to metabolic syndrome. Mutual adjustment attenuated the relation of metabolic syndrome with childhood social class; that with adult social class was little affected. However, the relation with adult social class was markedly attenuated by adjustment for smoking status, physical activity, and alcohol consumption. High waist circumference was independently associated with adult social class.

CONCLUSIONS

The association between adult social class and metabolic syndrome was largely explained by behavioral factors. In addition, central adiposity, a component of metabolic syndrome, was associated with adult social class. Focusing on healthier behaviors and obesity, rather than specific efforts to reduce social inequalities surrounding metabolic syndrome, is likely to be particularly important in reducing social inequalities that affect people with coronary disease.