Dietary patterns associated with a low-fat diet in the national health examination follow-up study: identification of potential confounders for epidemiologic analyses

To identify systematically the nutrient and food group intakes associated with a low-fat diet, the authors used the detailed dietary information collected from 10,306 individuals aged 32-86 years in the 1982-1984 National Health Epidemiologic Follow-up Study. Intakes of vitamin C and percentages of calories from carbohydrates, dietary fiber, poultry, low-fat dairy products, fruits, vegetables, cereals, and whole grains were markedly higher, while intakes of protein, total fat, saturated fat, oleic and linoleic acids, cholesterol, sodium, all red meats, high-fat dairy products, eggs, nuts, white bread, fried potatoes, desserts, fats, and oils were much lower in the quartile with the lowest percentage of calories from fat. These dietary patterns associated with a low-fat diet were essentially constant across strata of age, sex, race, and socioeconomic status. This study suggests that individuals on a low-fat diet substitute certain carbohydrate-rich foods such as fruits and vegetables for fat. Given these associations between low-fat diets and other dietary factors independently associated with certain cancers, these dietary factors should be considered potential confounders in studies of dietary fat and these cancers.     

The role of Ly49A and 5E6(Ly49C) molecules in hybrid resistance mediated by murine natural killer cells against normal T cell blasts

Due to affluence and a sedentary life style a great deal of people in the western countries are affected by coronary heart disease (CHD). The relation between CHD and certain risk factors pertaining to life style is evaluated in this study. A primary purpose is to study certain crucial risk factors for women. The main variables are age, smoking, overweight (measured by BMI), blood pressure and exercise. This prospective study is based on self-reported data from the nation-wide Swedish Level of Living Survey and on data from the national Cause of Death Register. The data were analysed separately by sex using a proportional hazards model. The sample was divided into two strata: those with heart disease and/or diabetes initially, and all the rest. A sample of 2546 men and 2760 women between 45 and 74 years of age was followed from 1980 to the end of 1990. During this period 189 men and 75 women died of coronary heart disease (CHD). It was found that high blood pressure raised the relative risk (RR) of death from CHD by almost 60% in both men and women. Male smokers (> 14 cigarettes a day) had about 60% (significant) and female smokers (> 10 cigarettes a day) 150% (significant) excessive mortality from CHD. Different levels of overweight among women were strongly related to excess mortality from CHD, ranging between 100 and 300%. Among men there was no such relation. Lack of physical activity showed only a weak (non-significant) increased risk of death due to CHD. Diabetes was also found to be an important risk factor for mortality from CHD, especially among women, being seven times as high as among non diabetics. A test of sex differences revealed that there were two significant interactions, namely between sex and overweight, and between sex and age. Background variables in relation to mortality from all cardiovascular diseases (CVD) were also studied. There were of course many similarities between the effects of the background variables in both the disease groups, but there were interesting differences too, e.g. overweight turned out to be a significant risk factor also for men and physical inactivity for women.     

Dietary interventions of human carcinogenesis

The diet is a complex mixture that is associated with approximately 30% of human cancer in the U.S. Extensive laboratory studies indicate that the diet is composed of many mutagens/carcinogens as well as antimutagens/anticarcinogens. Overwhelming evidence from epidemiological studies indicates that a diverse diet that is high in fruits and vegetables and low in certain fats, along with moderate caloric intake and exercise, is most closely associated with reduced cancer risk. Dietary intervention studies using complex food items (fruits, vegetables, and fats) support these epidemiological observations; dietary interventions using single compounds (vitamins, antioxidants, etc.) have generally not. Estimates suggest that appropriate dietary changes could reduce the percentage of deaths due to prostate, colorectal, pancreatic, and breast cancer by >/=50%.     

Depression and risk of coronary heart disease in elderly men and women: New Haven EPESE, 1982-1991. Established Populations for the Epidemiologic Studies of the Elderly

BACKGROUND: Results of several recent studies suggest that depression is predictive of incident coronary disease. However, few studies have examined this relationship in the elderly, the age at which most coronary heart disease (CHD) becomes clinically manifest. METHODS AND RESULTS: Data are from the New Haven, Conn, cohort (N = 2812) of the Established Populations for the Epidemiologic Studies of the Elderly project. Baseline information on depressive symptoms and CHD risk factors was collected during an in-person interview in 1982. Nonfatal myocardial infarctions were identified through monitoring of admissions to local hospitals and were validated by medical chart review. Cause of death was obtained from death certificates for all deceased participants. Outcomes were defined as CHD deaths (n = 255) and total incident CHD events (n = 391) between January 1, 1982, and December 31, 1991. There was no association between depressive symptoms and CHD outcomes in men. Among women, depressive symptoms were associated with an age-adjusted relative risk of 1.03 (per unit increase on the symptom scale) for CHD mortality (P=.001) and total CHD incidence (P=.002). These associations were largely unaffected by adjustment for established CHD risk factors but were reduced to nonsignificant levels after additional adjustment for impaired physical function. Additional analysis showed a significant association for depressive symptoms among women who had no physical function impairments or who survived at least 3 years without an event. CONCLUSION: Depressive symptoms may not be independent risk factors for CHD outcomes in elderly populations in general but may increase risk among relatively healthy older women.     

ERK2 signalling from internalised epidermal growth factor receptor in broken A431 cells

In this review the indications for the available treatments for dyslipidemias in the prevention of coronary heart disease (CHD) are considered, and their efficacy according to the latest studies is analyzed. As data sources the authors used the main multicenter studies performed in the last twenty years to evaluate primary and secondary prevention of CHD by correcting dyslipidemias as well as the results of meta-analyses of these studies. All treatments considered were found effective in preventing CHD morbidity and mortality to some extent. In particular, the combination of diet with niacin or hydroxymethylglutaryl coenzyme A (HMG CoA) reductase inhibitors seems to give the best results. These drugs induce a marked reduction of total and low-density lipoprotein (LDL) cholesterol and an increase of high-density lipoprotein (HDL) cholesterol concentrations. The use of diet, niacin, and HMG CoA reductase inhibitors reduces total as well as specific mortality. Treatment of dyslipidemia to prevent CHD depends on the pattern and severity of dyslipidemia, the presence of overt CHD, and the patient's response to diet. Pharmacologic treatment should be started only after dietary modifications have been tried and must be combined with diet. Drug side effects must also be considered, for they may affect patient compliance. High levels of total and LDL and low levels of HDL cholesterol are major risk factors for coronary atherosclerosis. Correcting lipid abnormalities can reduce the risk of development or progression of CHD. Diet and drugs are the main instruments available to normalize lipid levels. The choice of drug to combine with diet must be based on its specific effects on lipid metabolism, side effects, and efficacy in reducing CHD.     

Interethnic differences in coronary heart disease mortality in 25 populations: association with the angiotensin-converting enzyme DD genotype frequency

BACKGROUND: Despite changes in dietary habits and steadily increasing serum cholesterol concentrations, coronary heart disease (CHD) mortality rates in developed South-East Asian populations are still one quarter those in many Western populations. We propose that genetic factors may, in part, contribute to these differences in CHD mortality. DESIGN: Using an ecological study design, we have investigated the comparative roles of serum cholesterol concentration and the angiotensin-converting enzyme (ACE) homozygote deletion (DD) genotype frequency, which has recently been implicated in CHD mortality. METHODS: Using our genotyping data from local Chinese populations, together with previously published data on ACE gene frequency and cholesterol concentrations, we correlated ACE DD genotype frequencies and mean serum cholesterol concentrations with World Health Organization age-adjusted CHD mortality rates in 25 ethnically diverse populations. RESULTS: Although mean serum cholesterol accounted for 67% of the variance in CHD mortality rates for all populations (r=0.82, 95% Cl 0.63-0.92, n=25, P<0.001), the ACE DD frequency accounted for 61% of the variance in 'low' cholesterol populations (r=0.78, 95% Cl 0.43-0.91, n= 14, P<0.001) with no additional contribution from serum cholesterol concentration. Moreover, in the 'low' cholesterol population, mean serum cholesterol accounted for only 37% of the variance. CONCLUSION: We hypothesize that differences in the frequency of the ACE DD genotype in populations with low mean serum cholesterol concentrations may play some part in determining interethnic differences in CHD mortality rates.     

Contribution to the prenatal diagnosis of congenital cardiopathies

After concluding a local teaching program to obstetric echographists about prenatal diagnosis of congenital heart disease (CHD), we compared 2 periods of activity in fetal echocardiography, that before, lasting 3 and one half years (G.I) and the other 6 months after (G.II). During the second period 20 newborn consecutively admitted with CHD (G.III) were also studied. Teaching program protocol for the 10 district hospitals visited is described. The results show a rise from 25 to 58 foetus per month observed, comparing the two periods, being 4 and 7% respectively those referred with suspicion of CHD, and 54 and 33% the obstetric accuracy. Total incidence of CHD was 4,2%, 41 in G.I and 6 in G.II. Types of CHD, treatment and evolution are described, being the mortality 68 and 50% respectively. Of the 20 newborn from G.III, 90% had no prenatal diagnosis of CHD, being 30% high risk pregnancies. Mortality in this group was 20%, 50% in the newborn from high risk pregnancies; eight newborns were operated on without mortality, 5 to aortic coarctation and 2 with arterial switch for transposition. It is concluded the necessity of continuing teaching programs so that prenatal diagnosis of CHD may improve and the care of the newborn may so be anticipated and ameliorated.     

The synergistic effect of smoking and serum cholesterol on coronary heart disease.

Reviews the evidence of a synergistic interaction effect of smoking and elevated serum cholesterol on coronary heart disease (CHD) morbidity and mortality. Methodological issues involved in assessing smoking status, serum cholesterol, and CHD are discussed, and evidence is presented to support the notion that, in part, serum cholesterol, like smoking, is an index of a behavioral risk factor. Such a synergistic interaction is determined to exist, although improvements in methodology are needed to more clearly identify its magnitude. Studies demonstrating that serum cholesterol can be modified by dietary changes and studies exploring the interaction between smoking and cholesterol are evaluated. Possible mechanisms by which smoking and cholesterol may interact to produce CHD are considered. It is suggested that, if smoking cessation and dietary modification behavioral treatments are focused specifically on young and middle-age Americans who smoke and have elevated serum cholesterol, such treatments may increase their effectiveness in lowering the risk of CHD (benefit) without necessarily increasing their effort (cost). (5 p ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Plasma lipids are affected similarly by dietary lauric or palmitic acid in gerbils and monkeys

To compare the relative impact of dietary lauric acid (12:0) and palmitic acid (16:0) on plasma lipids, two fat-sensitive species, Mongolian gerbils and cebus monkeys, were fed cholesterol-free, purified diets enriched with either 12:0-rich or 16:0-rich fats, while all other fatty acids were held constant by selective blending of up to five natural fats or oils. The two gerbil diets (40 en% from fat) allowed for an 8 en% exchange between 12:0 and 16:0, and the monkey diets (31 en% from fat) allowed for 6 en% exchange between these two fatty acids. Eight gerbils received the diets for eight weeks, and 12 cebus monkeys were fed each diet in a cross-over design for up to 22 wk. Both diets resulted in similar plasma cholesterol, triglyceride, and high density lipoprotein cholesterol concentrations within each species. Additionally, separation of cebus lipoproteins by discontinuous density-gradient ultracentrifugation failed to show any dietary differences in concentration or composition of the three major lipoprotein classes (d < 1.019, 1.019-1.055, and 1.055-1.168 g/mL). Thus, in two species sensitive to manipulations in dietary fat while consuming cholesterol-free diets, 16:0 was not hypercholesterolemic relative to 12:0.     

Referral selection bias in the Medicare hospital mortality prediction model: are centers of referral for Medicare beneficiaries necessarily centers of excellence?

OBJECTIVE: Although the Health Care Financing Administration (HCFA) uses Medicare hospital mortality data as a measure of hospital quality of care, concerns have been raised regarding the validity of this concept. A problem that has not been fully evaluated in these data is the potential confounding effect of illness severity factors associated with referral selection and hospital mortality on comparisons of risk-adjusted hospital mortality. We address this issue. DATA SOURCES AND STUDY SETTING: We analyzed the 1988 Medicare hospitalization data file (MEDPAR). We selected data on patients treated at the two Mayo Clinic-associated hospitals in Rochester, Minnesota, and a group of seven other hospitals that treat many patients from large geographic areas. These hospitals have had observed mortality rates substantially lower than those predicted by the HCFA model for the period 1987-1990. STUDY DESIGN: Using the multiple logistic regression model applied by HCFA to the 1988 data, we evaluated the relationship between distance from patient residence to the admitting hospital and risk-adjusted hospital mortality. PRINCIPAL FINDINGS: Among patients admitted to Mayo Rochester-affiliated hospitals, residence outside Olmsted County, Minnesota was independently associated with a 33 percent lower 30-day mortality rate (p < .001) than that associated with residence in Olmsted County. When patients at Mayo hospitals were stratified by residence (Olmsted County versus non-Olmsted County), the observed mortality was similar to that predicted for community patients (9.6 percent versus 10.2 percent, p = .26), whereas hospital mortality for referral patients was substantially lower than predicted (5.0 percent versus 7.5 percent, p = < .001). After incorporation of the HCFA risk adjustment methods, distance from patient residence to the hospitals was also independently associated with mortality among the Mayo Rochester-affiliated hospitals and seven other referral center hospitals. CONCLUSIONS: The HCFA Medicare hospital mortality model should be used with extreme caution to evaluate hospital quality of care for national referral centers because of residual confounding due to severity of illness factors associated with geographic referral that are inadequately captured in the extant prediction model.     

Cholesterol reduction yields clinical benefit. A new look at old data

BACKGROUND: There has been a continuing debate about the overall benefit of cholesterol lowering. We performed a novel meta-analysis of all randomized trials of more than 2 years' duration (n = 35 trials) to describe how coronary-heart-disease (CHD), non-CHD, and total mortality are related to cholesterol lowering and to type of intervention. METHODS AND RESULTS: The analytic approach was designed to separate the effects of cholesterol lowering itself from the other effects of the different types of intervention used. For every 10 percentage points of cholesterol lowering, CHD mortality was reduced by 13% (P < .002) and total mortality by 10% (P < .03). Cholesterol lowering had no effect on non-CHD mortality. Certain types of intervention had specific effects independent of cholesterol lowering. Fibrates (clofibrates, 7 trials; gemfibrozil, 2 trials) increased non-CHD mortality by about 30% (P < .01) and total mortality by about 17% (P < .02). Hormones (estrogen, 2 trials; dextrothyroxin, 2 trials) increased CHD mortality in men by about 27% (P < .04), non-CHD mortality by about 55% (P < .03), and total mortality by about 33% (P < .01). No specific effects independent of cholesterol lowering were found due to diet (n = 11) or other interventions (resins, 5; niacin, 3; statins, 2; partial ileal bypass, 1). CONCLUSIONS: The results suggest that cholesterol lowering itself is beneficial but that specific adverse effects of fibrates and hormones increase the risk of CHD (hormones only), non-CHD, and total mortality.     

Are subjective clinical findings and objective clinical tests related to the motion characteristics of low back pain subjects?

OBJECTIVE: Examine the association between county occupational structure, public expenditures, services availability, prevalence of risk factors, and coronary mortality rates, for 1980-1994, in Washington state. DESIGN: Washington's 39 counties were classified into three occupational structure categories: counties with the lowest percentages of the labor force in managerial, professional, and technical occupations were classified in category I; counties with the highest percentages were in category III. Directly age-adjusted coronary heart disease (CHD) mortality rates, aged 35-64 years, (from vital statistics and Census data), per capita expenditures (Washington Department of Revenue data), per capita services (U.S. Statistical Abstracts data), and the prevalence of CHD risk factors (BRFSS data) were calculated for each occupational structure category. RESULTS: CHD mortality rates and the prevalence of risk factors were inversely associated with occupational structure. Per capita expenditures for health, social, and employment services were 2.2 times, and for schools and recreation were 1.4 times higher in category III vs. I counties. Per capita numbers of child care, job training, employment services, exercise facilities, schools, and medical services were 1.5-6.4 times greater in category III vs. I counties. CONCLUSIONS: Strategies to improve community living conditions and decrease economic disparities between counties may be important to decrease geographic differences in premature CHD mortality.     

Clinical trials of reducing low-density lipoprotein concentrations

Much diverse evidence suggests that the plasma levels of low-density lipoprotein (LDL) cholesterol play a causal role in the pathogenesis of atherosclerotic coronary heart disease. Until recently, clinical trials of LDL lowering, while showing significant reductions in coronary heart disease (CHD) rates, were not entirely convincing and left some questions of long-term toxicity unresolved. The results of a series of new trials using members of the powerful statin class of drugs are now being reported. Whether they are primary or secondary prevention studies, they have been uniformly successful in reducing mortality and morbidity from CHD and even total mortality, and have decreased the need for revascularization procedures. Their effectiveness is apparent in many different subgroups such as women, diabetics, hypertensives, and in stroke prevention. Statin drugs also have proven to be remarkably safe over the duration of the studies. Angiographic studies show an impact on coronary or carotid lesions.     

Dietary fats and lung cancer risk among women: the Missouri Women's Health Study (United States)

In a population-based case-control study of women in Missouri (United States), most of whom were smokers, we obtained information on adult diet to evaluate the effects of dietary fats in relation to lung cancer risk. All newly diagnosed, primary lung cancer cases among women 35 to 84 years of age reported to the Missouri Cancer Registry from 1 January 1993 to 31 January 1994 were invited to participate, as were population-based controls. The analysis focused on interviews obtained from 624 controls and 587 cases. In-person interviews were obtained from 99.0 percent of controls and 60.6 percent of cases. Age and energy-adjusted relative risks suggested a direct relation between risk of lung cancer and intake of dietary fats (e.g., total fat, saturated fat) and frequency of meat consumption. After adjusting for confounders, dietary fats were no longer associated with risk, but the adverse effect of frequent consumption of meat persisted. Risk was elevated about 90 percent (95 percent confidence interval = 1.2-3.0) among women in the highest quintile of red meat intake compared with those in the lowest quintile. Risk estimates associated with red meat consumption, however, were dependent on interview status; the effect was restricted to cases whose dietary information was provided by proxy. In summary, after adjusting for potential confounders and removing data obtained from proxy respondents, dietary fats and consumption of red meat were not associated with lung cancer risk among women in Missouri.     

Dietary therapy for preventing and treating coronary artery disease

Nearly one half of Americans die of cardiovascular disease. The morbidity and mortality associated with coronary artery disease is strongly related to abnormal lipid levels, oxidation of lipids and intra-arterial clot formation. Nutrition powerfully influences each of these factors. There is growing evidence that patients can improve lipid levels and decrease the rate of cardiovascular events by "adding" specific foods to their diets and switching from saturated and polyunsaturated to monounsaturated fats and n-3 fatty acids. Appropriate dietary changes decrease arteriosclerotic plaque formation, improve endothelial vasomotor dynamics, reduce oxidation of low-density lipoproteins and enhance thrombolytic activity. Brief discussions between physicians and patients can influence patients' food choices. Changes in diet can reduce the premature mortality and morbidity associated with coronary artery disease.     

The biological value of fats

Integral characteristics of animal development (weight increase, maturing of biological systems) used to date are not adequate to the requirements of detailed biological evaluation of dietary fats. The linoleic acid content in the dietary fat and the eicosatrienoic acid - eicosatetraenoic acid ratio (20:3/20:4 = HOLMAN coefficient) in the organism alone are also inadequate criteria. For this reason, the author attempted to establish metabolism-relevant law-like relationships between the fatty acid pattern of dietary fats and tissue lipids.     

The impact of unemployment on health: a review of the evidence

OBJECTIVE: To review the scientific evidence supporting an association between unemployment and adverse health outcomes and to assess the evidence on the basis of the epidemiologic criteria for causation. DATA SOURCES: MEDLINE was searched for all relevant articles with the use of the MeSH terms "unemployment," "employment," "job loss," "economy" and a range of mortality and morbidity outcomes. A secondary search was conducted for references from the primary search articles, review articles or published commentaries. Data and definitions of unemployment were drawn from Statistics Canada publications. STUDY SELECTION: Selection focused on articles published in the 1980s and 1990s. English-language reports of aggregate-level research (involving an entire population), such as time-series analyses, and studies of individual subjects, such as cross-sectional, case-control or cohort studies, were reviewed. In total, the authors reviewed 46 articles that described original studies. DATA EXTRACTION: Information was sought on the association (if any) between unemployment and health outcomes such as mortality rates, specific causes of death, incidence of physical and mental disorders and the use of health care services. Information was extracted on the nature of the association (positive or negative), measures of association (relative risk, odds ratio or standardized mortality ratio), and the direction of causation (whether unemployment caused ill health or vice versa). DATA SYNTHESIS: Most aggregate-level studies reported a positive association between national unemployment rates and rates of overall mortality and mortality due to cardiovascular disease and suicide. However, the relation between unemployment rates and motor-vehicle fatality rates may be inverse. Large, census-based cohort studies showed higher rates of overall mortality, death due to cardiovascular disease and suicide among unemployed men and women than among either employed people or the general population. Workers laid off because of factory closure have reported more symptoms and illnesses than employed people; some of these reports have been validated objectively. Unemployed people may be more likely than employed people to visit physicians, take medications or be admitted to general hospitals. A possible association between unemployment and rates of admission to psychiatric hospitals is complicated by other institutional and environmental factors. CONCLUSIONS: Evaluated on an epidemiologic basis, the evidence suggests a strong, positive association between unemployment and many adverse health outcomes. Whether unemployment causes these adverse outcomes is less straightforward, however, because there are likely many mediating and confounding factors, which may be social, economic or clinical. Many authors have suggested mechanisms of causation, but further research is needed to test these hypotheses.     

The relationship of hospital ownership and teaching status to 30- and 180-day adjusted mortality rates

Hospital characteristics have been shown previously to be associated with variations in the probability of death within 30 days of admission. In the current study, the authors extend the examination of the relationship between hospital type to both short-term and long-term adjusted mortality. Observed and predicted 1988 hospital mortality rates were obtained from the Health Care Financing Administration (HCFA). A total of 3,782 acute care hospitals were divided into six mutually exclusive groups on the basis of their status as osteopathic, private for-profit, public teaching, public nonteaching, private teaching, and private nonteaching hospitals. After adjusting for the HCFA predicted mortality, Medicaid admissions, and emergency visits, 30-day and 30-to-180-day patient mortality rates were compared for these hospital types. Separate comparisons also were performed after stratifying hospitals into three groups defined by community size. The risk-adjusted 30-day mortality per 1,000 patients was 91.5, ranging from 85.4 for private teaching hospitals to 95.3 for nonteaching public hospitals, and 97.4 for osteopathic hospitals. The adjusted 30-to-180-day mortality was 84.7, ranging from 82.6 for nonteaching public hospitals to 87.4 and 88.2, respectively for public teaching and osteopathic hospitals. Differences among hospital types were minimal for small communities and increased with community size. In the large communities, the types of hospitals with high 30-day mortality also had higher mortality after 30 days. There was a strong association of hospital type with adjusted 30-day mortality, which should depend on the quality of hospital care, and a much weaker association with post-30-day mortality, which may be more dependent on patient risk. There was no evidence that types of hospitals with low 30-day mortality were postponing rather than preventing mortality.     

Long-term prognosis of different forms of coronary heart disease: the Reykjavik Study

BACKGROUND: While coronary heart disease (CHD) is a serious and often fatal disease the prognosis is variable and major effort has been invested in risk stratification. The purpose of this study was to examine the relation between long-term prognosis and risk factors in different clinical categories of CHD. METHODS: A general population sample of 9141 men, aged 34-79 at entry into the study was divided into six groups with respect to manifestations of CHD at entry: I. Symptomatic infarction. II. Silent or unrecognized infarction. III. Angina pectoris with ischaemic changes on ECG. IV. Angina without ischaemic changes. V. Angina by Rose questionnaire but not confirmed by a physician. VI. No manifestations of CHD. RESULTS: The risk factor profile varied considerably between the different categories and by life-table analysis marked differences in survival were demonstrated between the groups. The risk factors maintained their detrimental effects on prognosis in the presence of CHD. Thus, age, serum total cholesterol, impaired glucose tolerance and smoking were found by Cox's regression to be statistically significant independent risk factors of CHD mortality among men having manifestations of CHD (groups I-V). Furthermore, the composite risk score, a measure of the overall risk factor exposures had marked effect on the prognosis of the various CHD groups. When the comprehensive risk factor score for both CHD mortality and all-cause mortality was accounted for marked differences persisted in the long-term prognosis. Compared to those without CHD the infarct groups had about a 7.6- and 3.7-fold risk of dying from CHD and all causes respectively. Those with angina had from 2.5- to 3.2-fold risk of CHD mortality and 1.7- to 2.2-fold risk of all-cause mortality depending on the subgroup of angina, again compared to those without manifestations of CHD. CONCLUSION: Different categories of CHD had different risk factor profiles and the long-term prognosis resulted from a complex interplay between those factors and the diagnostic category of CHD. The risk factors maintained their detrimental effects on prognosis in the presence of CHD and after accounting for the comprehensive risk factor score marked differences persisted in the long-term prognosis, being worst for those having suffered a myocardial infarction, either symptomatic or silent.