Incidence and prevalence of recognised and unrecognised myocardial infarction in women. The Reykjavik Study

AIMS: The incidence and prevalence of recognised and unrecognised myocardial infarction were determined in the Icelandic cohort study of 13,000 women (the Reykjavik Study), followed for up to 29 years (mean 15 years). METHODS AND RESULTS: Women attending the Reykjavik Study, born between 1908 and 1935, were examined in five stages from 1968 to 1991. A health survey included history and ECG manifestations of coronary heart disease. Data retrieved from hospitals, autopsy records and death certificates identified 596 fatal and non-fatal myocardial infarctions to the end of 1992 (61 prior to examination, 320 non-fatal and 215 fatal). The incidence of recognised myocardial infarction ranged from 22 cases/100,000/year at 35-39 years to 1800 cases/100,000/year at 75-79 years. The incidence of unrecognised myocardial infarction ranged from 18 cases/100,000/year at 35 years to 219 cases/100,000/year at 75 years. Thirty-three percent of non-fatal myocardial infarctions were unrecognised. More occurred in the younger age groups (40%) than in the older (27%). The prevalence of recognised myocardial infarction was influenced by age and calendar year. In 1990, it was 1.3/1,000 at 35 years and 60/1000 at 75 years. Prevalence showed a time trend, tripling in all age groups from 1968-1992. Fore unrecognised myocardial infarction, prevalence rose from 0.9/1000 at 35 years to 19.2/1000 at 75 years, although there was no evident time trend. CONCLUSION: Myocardial infarction in women is very age-dependent with both incidence and prevalence increasing continuously and steeply with age. There was a significant trend for an increase in prevalence of recognised myocardial infarction from 1968 to 1992. The proportion of unrecognised non-fatal infarctions ranged from 27% in the oldest age group to 40% in the youngest. On average, this form of coronary heart disease is as common as in men.     

Randomised trial of alpha-tocopherol and beta-carotene supplements on incidence of major coronary events in men with previous myocardial infarction

BACKGROUND: Epidemiological data suggest that the intake of antioxidants such as alpha-tocopherol (vitamin E) and beta-carotene has an inverse correlation with the incidence of coronary heart disease. The results from clinical trials of antioxidant supplementation in people with known coronary heart disease are inconclusive. METHODS: We studied the frequency of major coronary events in 1862 men enrolled in the alpha-tocopherol beta-carotene Cancer Prevention Study (smokers aged between 50 and 69 years) who had a previous myocardial infarction. In this randomised, double-blind. placebo-controlled study, men had received dietary supplements of alpha-tocopherol (50 mg/day), beta-carotene (20 mg/day), both, or placebo. The median follow-up was 5.3 years. The endpoint of this substudy was the first major coronary event after randomisation. Analyses were by intention to treat. FINDINGS: 424 major coronary events (non-fatal myocardial infarction and fatal coronary heart disease) occurred during follow-up. There were no significant differences in the number of major coronary events between any supplementation group and the placebo group (alpha-tocopherol 94/466; beta-carotene 113/461; alpha-tocopherol and beta-carotene 123/497; placebo 94/438 [log-rank test, p = 0.25]). There were significantly more deaths from fatal coronary heart disease in the beta-carotene (74/461, multivariate-adjusted relative risk 1.75 [95% CI 1.16-2.64], p = 0.007) and combined alpha-tocopherol and beta-carotene groups (67/497, relative risk 1.58 [1.05-2.40], p = 0.03) than in the placebo group (39/438), but there was no significant increase in the alpha-tocopherol supplementation group (54/466, relative risk 1.33 [0.86-2.05], p = 0.20). INTERPRETATION: The proportion of major coronary events in men with a previous myocardial infarction who smoke was not decreased with either alpha-tocopherol or beta-carotene supplements. In fact, the risk of fatal coronary heart disease increased in the groups that received either beta-carotene or the combination of alpha-tocopherol and beta-carotene; there was a non-significant trend of increased deaths in the alpha-tocopherol group. We do not recommend the use of alpha-tocopherol or beta-carotene supplements in this group of patients.     

Intake of trans fatty acids and risk of coronary heart disease among women

Trans isomers of fatty acids, formed by the partial hydrogenation of vegetable oils to produce margarine and vegetable shortening, increase the ratio of plasma low-density-lipoprotein to high-density-lipoprotein cholesterol, so it is possible that they adversely influence risk of coronary heart disease (CHD). To investigate this possibility, we studied dietary data from participants in the Nurses' Health Study. We calculated intake of trans fatty acids from dietary questionnaires completed by 85,095 women without diagnosed CHD, stroke, diabetes, or hypercholesterolaemia in 1980. During 8 years of follow-up, there were 431 cases of new CHD (non-fatal myocardial infarction or death from CHD). After adjustment for age and total energy intake, intake of trans isomers was directly related to risk of CHD (relative risk for highest vs lowest quintile 1.50 [95% Cl 1.12-2.00], p for trend = 0.001). Additional control for established CHD risk factors, multivitamin use, and intakes of saturated fat, monounsaturated fat, and linoleic acid, dietary cholesterol, vitamins E or C, carotene, or fibre did not change the relative risk substantially. The association was stronger for the 69,181 women whose margarine consumption over the previous 10 years had been stable (1.67 [1.05-2.66], p for trend = 0.002). Intakes of foods that are major sources of trans isomers (margarine, cookies [biscuits], cake, and white bread) were each significantly associated with higher risks of CHD. These findings support the hypothesis that consumption of partially hydrogenated vegetable oils may contribute to occurrence of CHD.     

Clinical characteristics of Meckel''s diverticulum in a population of children

BACKGROUND: Over the past 10-20 years, evidence has accumulated suggesting that it is not just biological risk factors that are important for the development of coronary heart disease. The present study is one of a series of case-control studies in which a wide range of psychosocial factors have been analysed in the same population to obtain information on their relationship with myocardial infarction, as well as of the interaction between psychosocial and biomedical variables. METHODS: The relationship between behavioural factors and non-fatal myocardial infarction was studied by comparing consecutively admitted male (n = 288) and female (n = 55) patients with a population sample of 283 men and 129 women. All participants were under 65 years of age. The behavioural variables (type-A behaviour, health locus of control, sleep problems and alcohol consumption) were investigated by means of a self-administered questionnaire. RESULTS: No significant differences emerged between patients with myocardial infarction and controls in terms of their type-A behaviour pattern. After controlling for traditional risk factors (smoking, hypertension, serum cholesterol level and diabetes), men with myocardial infarction reported a significantly stronger external health locus of control (i.e. a weak belief in their capacity to control their health) compared with their controls, as well as more problems with sleep and a lower alcohol consumption; women with myocardial infarction reported significantly more problems with sleep than their controls. CONCLUSION: The importance of health locus of control, sleep problems and alcohol consumption is amplified by the fact that they are related to myocardial infarction independently of conventional biomedical risk factors. These behavioural factors should be studied further in prospective investigations.     

Preinfarction blood pressure and smoking are determinants for a fatal outcome of myocardial infarction: a prospective analysis from the Finnmark Study

BACKGROUND: Serum cholesterol levels, blood pressure, and smoking are the classic coronary risk factors, but what determines whether a myocardial infarction will be fatal or not? OBJECTIVE: To investigate cardiovascular risk factors that may influence survival in subjects with coronary heart disease (myocardial infarction and sudden death). SUBJECTS AND METHODS: All inhabitants aged 35 to 52 years in Finnmark County, Norway, were invited to a cardiovascular survey in 1974-1975 and/or 1977-1978. Attendance rate was 90.5%. A total of 6995 men and 6320 women were followed up for 14 years with regard to incident myocardial infarction and sudden death. Predictors for 28-day case fatality rate after first myocardial infarction were analyzed. RESULTS: During 186 643 person-years, 635 events among men and 125 events among women were registered. The case fatality rate was 31.6% in men and 28.0% in women (P =.50). Among men (women) with baseline systolic blood pressure lower than 140 mm Hg, the 28-day case fatality rate was 24.5% (22.6%), among those with systolic blood pressure of 140 through 159 mm Hg, the case fatality rate was 35.6% (28.2%), and among those with systolic blood pressure of 160 mm Hg or higher, the case fatality rate was 48.2% (41.7%). Of the 760 subjects with myocardial infarction, 348 died during follow-up. In Cox regression analysis, systolic blood pressure at baseline was strongly related to death (relative risk per 15 mm Hg, 1.22; 95% confidence interval, 1.13-1.31). Daily smoking at baseline (relative risk, 1.40; 95% confidence interval, 1.07-1.85) and age at time of event (relative risk per 5 years, 1.12; 95% confidence interval, 1.01-1.24) were additional significant risk factors, while total serum and high-density lipoprotein cholesterol levels were unrelated to survival. Similar results were obtained with diastolic blood pressure in the model. CONCLUSIONS: Preinfarction blood pressure was an important predictor of case fatality rate in myocardial infarction. Daily smoking and age were additional significant predictors.     

Diabetes mellitus and morbidity and mortality risks after coronary artery bypass surgery

Of 1025 patients (912 men, 113 women) who underwent coronary artery bypass grafting and were followed up for a mean of 7.4 years, 45 (4.4%) had diabetes mellitus. Norwegian population is 1.8-2%). Early mortality was not significantly greater among diabetics than in non-diabetics (2.2 vs. 3.1%, odds ratio--OR-0.44, confidence interval--CI- 0.05-3.56). Diabetic patients had no increased risk of perioperative myocardial infarction (OR = 0.87, CI 0.36-2.10) or of low-output syndrome necessitating intraortic balloon pumping (OR = 0.42, CI 0.55-3.05), and no excess incidence of late non-fatal myocardial infarction (relative risk = 0.69, CI 0.10-1.28) or late chronic heart failure (OR = 2.50, CI 0.5-11.0). Long-term mortality was increased in the diabetic patients (relative risk 1.87, CI 1.60-2.14). Thus diabetes did not entail heightened risk of early mortality, perioperative myocardial infarction or low-output syndrome. Nor was there excess risk of recurrent angina pectoris, late non-fatal myocardial infarction or chronic heart failure among the diabetic patients, but the late mortality risk was increased.     

Heart, brain and hypertension

Hypertension is one of the most important cardiovascular risk factors. Without therapy hypertension leads to stroke, coronary heart disease with angina pectoris and myocardial infarction, kidney failure and/or peripheral vascular disease. The association between blood pressure and these cardiovascular complications can be demonstrated over the entire blood pressure range. The risk of stroke, myocardial infarction, renal failure or peripheral vascular disease increases with increasing blood pressure. Additional cardiovascular risk factors such as hyperlipidemia, smoking and diabetes involve a further increase in risk. Today hypertension can be effectively treated. To that end, diuretics, betablockers, ACE-inhibitors or calcium antagonists can be used. Alpha receptor antagonists and angiotensin AT1 receptor antagonists are also of value. The antihypertensive effectiveness of these drugs is comparable but may vary in individual patients. During antihypertensive therapy, a reduction in cerebrovascular and cardiac complications has been demonstrated for alpha methyldopa, diuretics and betablockers. In these studies, fatal and non-fatal strokes were reduced by 42%, while the reduction in cardiac events was less pronounced (14%). The reasons for this greater efficacy of antihypertensive therapy in the cerebral circulation are not clear. Other risk factors may be particularly important in the pathogenesis of coronary artery disease (e.g. genetic factors, hyperlipidemia and others) or hypertensive vascular changes in the coronary circulation may not be as reversible as they are in the cerebral circulation. The well documented correlation between stroke, myocardial infarction and hypertension, as well as the proven efficacy of antihypertensive therapy in preventing cardiovascular events, underscores the importance of effective and sustained blood pressure control in these patients.     

Effect of vitamin E and beta carotene on the incidence of primary nonfatal myocardial infarction and fatal coronary heart disease

BACKGROUND: Oxidized low-density lipoprotein is involved in the pathogenesis of atherosclerosis. In epidemiological studies antioxidants have been inversely related with coronary heart disease. Findings from controlled trials are inconclusive. METHODS: We studied the primary preventive effect of vitamin E (alpha tocopherol) and beta carotene supplementation on major coronary events in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study, a controlled trial undertaken primarily to examine the effects of these agents on cancer. A total of 27 271 Finnish male smokers aged 50 to 69 years with no history of myocardial infarction were randomly assigned to receive vitamin E (50 mg), beta carotene (20 mg), both agents, or placebo daily for 5 to 8 years (median, 6.1 years). The end point was the first major coronary event, either nonfatal myocardial infarction (surviving at least 28 days; n = 1204) or fatal coronary heart disease (n = 907). RESULTS: The incidence of primary major coronary events decreased 4% (95% confidence interval, -12% to 4%) among recipients of vitamin E and increased 1% (95% confidence interval, -7% to 10%) among recipients of beta carotene compared with the respective nonrecipients. Neither agent affected the incidence of nonfatal myocardial infarction. Supplementation with vitamin E decreased the incidence of fatal coronary heart disease by 8% (95% confidence interval, -19% to 5%), but beta carotene had no effect on this end point. CONCLUSIONS: Supplementation with a small dose of vitamin E has only marginal effect on the incidence of fatal coronary heart disease in male smokers with no history of myocardial infarction, but no influence on nonfatal myocardial infarction. Supplementation with beta carotene has no primary preventive effect on major coronary events.     

Influence of fathers' social class on cardiovascular disease in middle-aged men

BACKGROUND: The independent effect of early life circumstances on adult cardiovascular risk is still unresolved. We assessed the associations of father's social class with cardiovascular risk factors and with risk of ischaemic heart disease and stroke in adult life. METHODS: We did a longitudinal study of cardiovascular disease in 5934 men aged 40-59 years at enrollment. A cross-sectional measurement survey was done between 1978 and 1980 and a follow-up questionnaire was completed in 1992. The main endpoints were non-fatal myocardial infarction and stroke based on general practitioners' reports obtained between screening and 1992 and on recall of physician-diagnosed ischaemic heart disease in the 1992 questionnaire. FINDINGS: Father's social class was strongly associated with social class in adulthood (fathers' occupation was manual for 41.3% of professionals [I] vs 89.1% for unskilled manual workers [V]) and was significantly related to height (non-manual vs manual 175.4 cm [SE 0.2] vs 172.9 cm [0.1], p < 0.0001) and obesity (213 [14.1%] vs 804 [20.1%], p < 0.0001) irrespective of adult social class; no association was found with blood glucose (log, 1.69 [0.005] vs 1.70 [0.003], p = 0.22) or cholesterol (6.34 [0.03] vs 6.29 mmol/L [0.02], p = 0.16. Men whose fathers' social class was manual had significantly higher rates of non-fatal myocardial infarction (342/4006 vs 92/1510) and self-reported physician-diagnosed ischaemic heart disease (686/4006 vs 192/1510) than men whose fathers' social class was non-manual, even after adjustment for adult social class and other established risk factors (relative odds 1.3 [95% Cl 1.0-1.7], p < 0.05 and 1.3 [1.1-1.6], p < 0.01, respectively). The influence of father's social class on non-fatal myocardial infarction and ischaemic heart disease was only seen in men whose adult social class was non-manual. No association was seen between father's social class and non-fatal stroke. INTERPRETATION: Father's social class is strongly associated with adult social class. The higher risk of non-fatal myocardial infarction and self-reported physician-diagnosed ischaemic heart disease seen in men whose father's social class was manual suggests that socioeconomic status early in life has some persisting influence on ischaemic heart disease risk in adult life.     

Self-rated health as a predictor of ischemic heart disease development

The study objective was to analyse the association between self-rated health and the incidence of fatal and non-fatal coronary heart disease in a Danish cohort followed up over 16 years. The study included 1052 men and women born in 1936. During the 16 years' follow-up 50 cases of coronary heart disease were registered either with the Danish register of deaths or the register of hospital admissions. Univariate analysis showed the following relative risks of coronary heart disease in the four self-rated health groups: "extremely good": 1.0, "good": 4.0, "poor": 5.8, "miserable": 12.1 (p = 0.02). After control for the conventional coronary risk factors and a substantial number of other potential confounders the relative risks were: 1.0, 4.2, 6.5, and 18.6 (p = 0.02) respectively. Self-rated health was an independent predictor of coronary heart disease in this recent cohort. If confirmed, the association between self-rated health and coronary heart disease may lead to new insights into psychosocial processes leading to this disease.     

Undergraduate and postgraduate clinical education in Kobe University School of Medicine

A total of 4,849 male participants of the prospective cardiovascular Münster Study (PROCAM), aged 40 - 65 years underwent extensive screening for cardiovascular risk factors before 1986 and were subsequently followed up for at least 8 years. During this time 189 non-fatal and 49 fatal myocardial infarctions occurred, 28 men suffered a sudden cardiac death and 169 persons died of other causes. Using multivariate statistical methods we confirmed that age, increased LDL cholesterol levels, decreased HDL cholesterol levels, high blood pressure, cigarette smoking, diabetes mellitus, angina pectoris and a positive family history are important risk factors for a myocardial infarction or cardiac death. The results of the PROCAM Study demonstrate that elevated triglycerides are an independent risk factor for an early myocardial infarction or cardiac death. Using a multiple logistic function analysis an algorithm for the assessment of the global risk was derived from the data. The observed incidence of coronary heart disease rises sharply as the global risk increases, thus permitting the use of this algorithm in clinical practice for the assessment of the individual risk of myocardial infarction. Risk factors such as lipoprotein(a) and coagulation factors may improve the predictive value of this algorithm. Furthermore it is expected that the exploration of genetic defects will strongly increase the predictive value and precise determination of individual risk.     

Serum homocysteine and risk of coronary heart disease and cerebrovascular disease in elderly men: a 10-year follow-up

Hyperhomocysteinemia is an independent risk factor for atherosclerotic disease in the middle-aged. We investigated whether a high serum homocysteine level is a risk factor for vascular disease in 878 elderly men (mean age at baseline, 71.5 years; range, 64 to 84 years) in a population-based, representative cohort followed up for 10 years in Zutphen, the Netherlands. Thirty-one percent had nonfasting homocysteine levels >/=17 micromol/L. After adjustment for other major risk factors, high homocysteine levels at baseline (the third compared with the first tertile) were associated with an increased baseline prevalence of myocardial infarction (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.07 to 3.08; P for trend, 0.03) and with a marginally significant increase in the risk of dying of coronary heart disease (relative risk [RR], 1.58; 95% CI, 0.93 to 2.69; P for trend, 0.09) but not with an increased risk of first-ever myocardial infarction. In addition, high homocysteine levels at baseline were associated with an increased baseline prevalence of stroke (OR, 4.61; 95% CI, 1.79 to 11.89; P for trend, 0.002) and with an increased risk of dying of cerebrovascular disease in subjects without hypertension (RR, 6.18; 95% CI, 2.28 to 16.76) but not in those with hypertension. High homocysteine levels were associated with an increased risk of first-ever stroke among normotensive subjects that was not statistically significant (RR, 1. 77 [95% CI, 0.83 to 3.75; P for trend, 0.14]). In a general population of elderly men, a high homocysteine level is common and is strongly associated with the prevalence of coronary heart disease and cerebrovascular disease. It is a strong predictive factor for fatal cerebrovascular disease in men without hypertension but less so for coronary heart disease.     

Prospective study of calcium channel blocker use, cardiovascular disease, and total mortality among hypertensive women: the Nurses' Health Study

BACKGROUND: In several observational studies, patients prescribed calcium channel blockers had higher risks of cardiovascular diseases and mortality than those prescribed other antihypertensive medications. We explored these associations in the Nurses' Health Study. METHODS AND RESULTS: A total of 14 617 women who reported hypertension and regular use of diuretics, beta-blockers, calcium channel blockers, ACE inhibitors, or a combination in 1988 were included in the analyses. Cardiovascular events and deaths were ascertained through May 1, 1994. We documented 234 cases of myocardial infarction. Calcium channel blocker monodrug users had an age-adjusted relative risk (RR) of myocardial infarction of 2.36 (95% CI, 1.43 to 3.91) compared with those prescribed thiazide diuretics. Women prescribed calcium channel blockers had a higher prevalence of ischemic heart disease. After adjustment for these and other coronary risk factors, the RR was 1.64 (95% CI, 0.97 to 2.77). Comparing the use of any calcium channel blocker (monodrug and multidrug users) with that of any other antihypertensive agent, the adjusted RR was 1.42 (95% CI, 1.01 to 2.01). An association between calcium channel blocker use and myocardial infarction was apparent among women who had ever smoked cigarettes (covariate-adjusted RR, 1.81; 95% CI, 1.20 to 2.72) but not among never-smokers (RR, 0.94; 95% CI, 0.48 to 1.84). CONCLUSIONS: In analyses adjusted only for age, we found a significant elevation in RR of total myocardial infarction among women who used calcium channel blockers compared with those who did not. After adjustment for comorbidity and other covariates, the RR was reduced. Whether the remaining observed elevated risk is real, or a result of residual confounding by indication, or chance, or a combination of the above cannot be evaluated with certainty on the basis of these observational data.     

Prospective study of shift work and risk of coronary heart disease in women

BACKGROUND: The purpose of this study was to examine prospectively the relation of shift work to risk of coronary heart disease (CHD) in a cohort of women. METHODS AND RESULTS: An ongoing prospective cohort of US female nurses, in whom we assessed (in 1988) the total number of years during which they worked rotating night shifts (at least three nights per month in addition to day and evening shifts), included 79,109 women, 42 to 67 years old in 1988, who were free of diagnosed CHD and stroke. Incident CHD was defined as nonfatal myocardial infarction and fatal CHD. During 4 years of follow-up (1988 to 1992), 292 cases of incident CHD (248 nonfatal myocardial infarction and 44 fatal CHD) occurred. The age-adjusted relative risk of CHD was 1.38 (95% CI, 1.08 to 1.76) in women who reported ever doing shift work compared with those who had never done so. The excess risk persisted after adjustment for cigarette smoking and a variety of other cardiovascular risk factors. Compared with women who had never done shift work, the multivariate adjusted relative risks of CHD were 1.21 (95% CI, 0.92 to 1.59) among women reporting less than 6 years and 1.51 (95% CI, 1.12 to 2.03) among those reporting 6 or more years of rotating night shifts. CONCLUSIONS: These data are compatible with the possibility that 6 or more years of shift work may increase the risk of CHD in women.     

Coffee, alcohol and risk of coronary heart disease among Japanese men living in Hawaii

We examined the relation of coffee and alcohol consumption to the risk of coronary heart disease during a six-year period in a cohort of 7705 Japanese men living in Hawaii. The analysis was based on 294 new cases of coronary heart disease. There was a positive association between coffee intake and risk, but it became statistically insignificant when cigarette smoking was taken into account. There was a strong negative association between moderate alcohol consumption (up to 60 ml per day), mainly from beer, and the risk of nonfatal myocardial infarction and death from coronary heart disease. This association remained significant in multivariate analysis, taking into account smoking and other risk factors. The correlation of alcohol consumption with the level of alpha cholesterol (positive) and beta cholesterol (negative) may partly account for the observed negative association between alcohol and coronary heart disease.     

The traditional and emerging role of nuts in healthful diets

Throughout history, nuts have been a staple food providing energy, protein, essential fatty acids, vitamins, and minerals. Today, nuts are classified as part of the USDA Food Guide Pyramid's Meat/ Meat Alternate Group. Foods in this group contribute protein as well as important vitamins and minerals to the diet. Nuts are also being studied for their potential health benefits. Research suggests that there may be a connection between frequent nut consumption and a reduced incidence of coronary heart disease. Thus, tradition and promising scientific evidence combine to support the role of nuts in healthful eating.     

Prognosis in men and women coming to the emergency room with chest pain or other symptoms suggestive of acute myocardial infarction

BACKGROUND: Previous studies suggest a gender-related difference in prognosis among patients with ischaemic heart disease. In the present study, we aimed to describe the characteristics and prognosis among patients with suspected ischaemic heart disease in relation to gender. METHODS: During the 21 months of the study, all patients who came to the medical emergency room of one single hospital as a result of chest pain or other symptoms suggestive of acute myocardial infarction were prospectively followed for 1 year. RESULTS: A total of 5362 patients were admitted on 7157 occasions; men accounted for 55% of the admissions. The 1-year mortality rate was 11% for men compared with 10% for women. The women were older and had a higher prevalence of known congestive heart failure and hypertension, whereas the prevalence of previous myocardial infarction was higher in men. When correcting for the dissimilarities in age and history of cardiovascular diseases, male gender appeared as an independent predictor of death. Development of myocardial infarction occurred in 25% of the men and 16% of the women (P < 0.001) during 1 year. The symptoms that brought patients to the emergency room were interpreted as being caused by myocardial infarction or myocardial ischemia in 29% of men compared with 21% of women (P < 0.001). CONCLUSIONS: In a consecutive series of patients with chest pain or other symptoms suggesting acute myocardial infarction in the emergency room, male gender was an independent risk indicator for death during 1 year. This might be explained by a higher occurrence of coronary artery disease in men than in women in this patient population.     

Perinatal mortality and its relationship to the reporting of low-birthweight infants

OBJECTIVE: To determine whether diabetes defined by isolated postchallenge hyperglycemia (IPH) (2-h postchallenge plasma glucose > or = 11.1 mmol/l with fasting plasma glucose [FPG] < 7.0 mmol/l) increases the risk of fatal cardiovascular disease (CVD) in older women and men. RESEARCH DESIGN AND METHODS: In a prospective study, we followed 769 men and 1,089 women, aged 50-89 years, who had no history of diabetes or myocardial infarction and demonstrated no fasting hyperglycemia (i.e., FPG < 7.0 mmol/l) when they underwent oral glucose tolerance testing at baseline in 1984-1987. RESULTS: At baseline, 70% of 125 women and 48% of 133 men with previously undiagnosed diabetes had IPH. Over the next 7 years, women with IPH had a significantly increased risk of fatal CVD and heart disease compared with nondiabetic women. This increased risk was not observed in men with IPH. This association was independent of age, hypertension, central obesity, cigarette smoking, HDL cholesterol, and triglycerides (multiply adjusted hazard ratio and 95% CI: 2.6 and 1.4-4.7 for CVD; 2.9 and 1.3-6.4 for heart disease). CONCLUSIONS: Diabetes defined by IPH alone is common in older adults and more than doubles the risk of fatal CVD and heart disease in older women. Because the prevalence of IPH increases with age, the use of fasting glucose alone for diabetes screening or diagnosis may fail to identify most older adults at high risk for CVD and should be reevaluated.     

Complications prior to revascularization among patients waiting for coronary artery bypass grafting and percutaneous transluminal coronary angioplasty

AIM: To describe the occurrence of death, development of acute myocardial infarction and need for hospitalization among patients on the waiting list for coronary artery bypass grafting and percutaneous transluminal coronary angioplasty. PATIENTS AND METHODS: All the patients on the waiting list for possible coronary revascularization in September 1990 in western Sweden. RESULTS: Of 718 patients waiting for either coronary artery bypass grafting or percutaneous transluminal coronary angioplasty, 15 (2.1%) died between the actual week in September 1990 and prior to revascularization and 12 (1.7%) developed a non-fatal acute myocardial infarction during the same period. All 15 patients who died before undergoing revascularization died a cardiac death. Death and/or the development of an acute myocardial infarction was significantly more frequent among the elderly, among patients with a low ejection fraction and among patients with a history of diabetes mellitus. In all, 29% required hospitalization prior to the procedure. The most common reason was symptoms of angina pectoris requiring hospitalization in 23% of the patients. CONCLUSION: Among patients on the waiting list before either coronary artery bypass grafting or percutaneous transluminal coronary angioplasty, 15 (2.1%) died prior to the procedure and 1.7% developed a non-fatal acute myocardial infarction. The risk of either death or developing an acute myocardial infarction was highest among patients in the older age groups, among patients with a history of diabetes mellitus and among patients with a lower ejection fraction.     

Dietary fat intake and the risk of coronary heart disease in women

BACKGROUND: The relation between dietary intake of specific types of fat, particularly trans unsaturated fat and the risk of coronary disease remains unclear. We therefore studied this relation in women enrolled in the Nurses' Health Study. METHODS: We prospectively studied 80,082 women who were 34 to 59 years of age and had no known coronary disease, stroke, cancer, hypercholesterolemia, or diabetes in 1980. Information on diet was obtained at base line and updated during follow-up by means of validated questionnaires. During 14 years of follow-up, we documented 939 cases of nonfatal myocardial infarction or death from coronary heart disease. Mutivariate analyses included age, smoking status, total energy intake, dietary cholesterol intake, percentages of energy obtained from protein and specific types of fat, and other risk factors. RESULTS: Each increase of 5 percent of energy intake from saturated fat, as compared with equivalent energy intake from carbohydrates, was associated with a 17 percent increase in the risk of coronary disease (relative risk, 1.17; 95 percent confidence interval, 0.97 to 1.41; P=0.10). As compared with equivalent energy from carbohydrates, the relative risk for a 2 percent increment in energy intake from trans unsaturated fat was 1.93 (95 percent confidence interval, 1.43 to 2.61; P<0.001); that for a 5 percent increment in energy from monounsaturated fat was 0.81 (95 percent confidence interval, 0.65 to 1.00; P=0.05); and that for a 5 percent increment in energy from polyunsaturated fat was 0.62 (95 percent confidence interval, 0.46 to 0.85; P= 0.003). Total fat intake was not signficantly related to the risk of coronary disease (for a 5 percent increase in energy from fat, the relative risk was 1.02; 95 percent confidence interval, 0.97 to 1.07; P=0.55). We estimated that the replacement of 5 percent of energy from saturated fat with energy from unsaturated fats would reduce risk by 42 percent (95 percent confidence interval, 23 to 56; P<0.001) and that the replacement of 2 percent of energy from trans fat with energy from unhydrogenated, unsaturated fats would reduce risk by 53 percent (95 percent confidence interval, 34 to 67; P<.001). CONCLUSIONS: Our findings suggest that replacing saturated and trans unsaturated fats with unhydrogenated monounsaturated and polyunsaturated fats is more effective in preventing coronary heart disease in women than reducing overall fat intake.