Knowledge and beliefs about smoking and goals for smoking cessation in hospitalized men with cardiovascular disease

OBJECTIVES

To describe perceptions of smoking in men hospitalized with cardiovascular disease (CVD).

BACKGROUND

Smoking is a major risk factor and associated with the high prevalence of CVD in Jordan.

METHODS

The study design was cross-sectional with a convenience sample. A structured interview was conducted in 112 men who were hospitalized with CVD.

RESULTS

The study showed that 91% of men hospitalized with CVD smoked daily. The majority (83%) had attempted to quit smoking in the past without help from others, and intended to quit in the future using the same previously unsuccessful method. They were unaware of the hazards of smoking such as stroke; or the long term health benefits of quitting smoking. Logistic regressions showed that men were more confident in quitting smoking if they had a high income (OR: 7.7; 95% CI: 2.7, 22.3), longer hospitalizations (OR: 2.6; 95% CI: 1.3, 5.3), or were hospitalized in acute cardiac settings (OR: 3.9; 95% CI: 1.2, 12.7), and admitted with a diagnosis of MI or angina (OR: 3.0; 95% CI: 1.1, 8.3).

CONCLUSION

Assessment of smoking status with smoking cessation counseling is paramount in hospitalized men with CVD who smoke.

Pain-coping strategies in women with ischemic heart disease

INTRODUCTION AND OBJECTIVE

The objective of the study was evaluation of the level and structure of anxiety and fear, and the characteristics of pain coping strategies used by females with ischemic heart disease (IHD). The detailed aim was assessment of the mutual relationships between the fear and pain coping strategies applied.

MATERIAL AND METHODS

The study covered 75 females aged 33-80 (mean age 61; SD±9.66), hospitalized in the Cardiology Clinic who had coronary angiography performed in order to assess the state of coronary vessels. Psychological studies were conducted by means of the IPAT Anxiety Scale by R. B. Cattell and the Pain Coping Strategies Questionnaire CSQ by A. C. Rosenstiel and F. J. Keefe.

RESULTS

The results obtained indicated that in the group of 75 females with IHD in the structure of anxiety and fear there dominated strong tendencies towards self-blaming and the experiencing of a sense of guilt, as well as a high level of internal tension. The strategy of the greatest importance in coping with pain among females with IHD was 'Praying and Hoping'. The strategies used with similar frequency were: 'Coping Self-Statements', 'Diverting Attention' and 'Increased Behavioural Activities'.

CONCLUSIONS

In females with IHD, the application of psychotherapy is recommended, aimed at reducing the level of auto-aggression tendencies and decreasing a high level of internal tension. Psychotherapeutic activities carried out among females with ischemic heart disease should focus on the strengthening of strategies of coping with pain, such as: 'Coping Self- Statements', 'Increased Behavioural Activities', and focusing attention on serious life problems.

The MacNew Heart Disease Health-Related Quality of Life Questionnaire in patients with angina and patients with ischemic heart failure

OBJECTIVE

Patient-reported outcomes including health-related quality of life are important in clinical care and research studies. The MacNew Heart Disease Health-Related Quality Of Life Questionnaire has been validated in English-speaking patients with myocardial infarction. The aim of this study was to validate the MacNew in English-speaking patients with angina or ischemic heart failure.

METHODS

Canadian and American patients with angina or ischemic heart failure completed the MacNew, the Short Form-36 Health Survey, and the Hospital Anxiety and Depression Scale.

RESULTS

We administered questionnaires to 276 patients with angina (mean age, 65.9 years) and 155 patients with ischemic heart failure (mean age, 70.3 years). The mean ± SD MacNew global score in patients with ischemic heart failure (5.1 ± 1.2) was statistically (P < 0.001), but not clinically, poorer than in patients with angina (5.3 ± 1.1). The three-factor measurement model explained 46.1% of the observed variance in the MacNew in patients with angina and 46.5% in patients with ischemic heart failure. Internal consistency was ≥0.90, and test-retest reliability was ≥0.70 for each MacNew scale and the a priori convergent and discriminative validity hypotheses were confirmed in both diagnoses. The MacNew was highly accepted by patients with little respondent or administrative burden.

CONCLUSIONS

The English version of the MacNew is reliable and valid in patients with angina or ischemic heart failure. This permits health-related quality of life outcome comparisons in patients with angina, ischemic heart failure, and myocardial infarction with the MacNew and provides a better understanding of the full range of health-related quality of life outcomes.

[Quality of life in patients of different age groups with ischemic heart disease: effect of multifocal atherosclerosis]

The aim of the research was to study the quality of life for the patients of different age groups with coronary artery disease and to evaluate the factors affecting its decline. The present study included 709 patients aged 31 to 79 years examined before elective coronary artery bypass graft surgery. All patients underwent coronary angiography, echocardiography, ultrasonography of the aorta, brachiocephalic, and peripheral arteries. With age, significantly increased incidence of multifocal atherosclerosis (p = 0.01 for the trend). To study the quality of life (QL) a non-specific questionnaire SF-36 was used, according to which the reduction of QL equally in all the groups (p > 0.05) was detected. Multivariate analysis showed that the level of QL was influenced by diabetes, myocardial infarction and the presence of multifocal atherosclerosis (p < 0.05). Thus, in order to improve the QL in aged patients with multifocal atherosclerosis is reasonable to conduct of reconstructive operations at different arterial basins.

[The interdependence of coronary pain control and level of anxiety in women with ischiaemic heart disease]

Interdependences between pain and anxiety in cardiac ischaemia are multidimensional and complex. Both of these phenomena share a lot of traits and they tend to reinforce each other at physiological level. Apart from arduousness of pain, cognitive understanding of its nature becomes an important mediating factor. One of important characteristics of the patient's attitude towards their illness is localization of pain control. The aim of the study was to analyze an interdependence between an anxiety as a state and as a trait and the localization of pain control in women with coronary heart decease.

MATERIAL AND METHODS

The study included 52 female patients hospitalised at The Department of Cardiology of The Medical University of Lublin who underwent coronarography. The used methods included an interview, State - Trait Anxiety Inventory of Spielberger (STAI) and The Beliefs about Pain Control Questionnaire (BPCQ).

RESULTS

The results did not confirm an often suggested opinion that internal localization of pain control reduces anxiety and activates the patient. The intensity of the internal localization of pain control correlates significantly with the intensity of the dependence of pain of activity of the doctors as well as on the anxiety as trait. It is higher in women with lower education. Perhaps better educated patients, not so ready to react with anxiety, can treat pain more realistically as a sign of a pathological process which can be understood and evaluated not so much as a catastrophe. They do not feel personally responsible for the pain, either, and are able to accept the limits of the doctor's assistance, having no unrealistic expectations with regard to the pain treatment.

CONCLUSIONS

The results of the research indicate that in women with ischiaemic heart decease better adjustment to the illness and a lower level of anxiety as a trait are connected with the understanding and acceptance of their situation by the patient, rather than with too big extent of expectations towards the control of pain by the patients themselves or medical staff.

[Association of ischemic heart disease with some psychosocial risk factors in male population aged 25-64 years]

Aim of the study was elucidation of association between prevalence of ischemic heart disease (IHD) with high levels of psychosocial risk factors in open male population aged 25-64 years. We examined a representative sample of men aged 25-64 years formed from electoral lists in one of administrative districts in Tyumen. In a framework of cardiological screening we studied prevalence of IHD and levels of psychosocial risk factors - personality anxiety and depression - using standard WHO questionnaire MONICA-psychosocial. IHD prevalence among men aged 25-64 years in Tyumen was 12.4%. Among men of this age high levels of psychosocial risk factors were more frequent - in men with IHD than in men without IHD. In men with high levels of psychosocial risk factors we observed increase of risk of development of acute (A)IHD. Increases of risk of AIHD and IHD in the presence of personal anxiety or depression were characteristic for age categories 55-64 and 45-64 years, respectively.

Observed hostility and the risk of incident ischemic heart disease: a prospective population study from the 1995 Canadian Nova Scotia Health Survey

OBJECTIVES

The aim of this study was to examine the relation between hostility and incident ischemic heart disease (IHD) and to determine whether observed hostility is superior to patient-reported hostility for the prediction of IHD in a large, prospective observational study.

BACKGROUND

Some studies have found that hostile patients have an increased risk of incident IHD. However, no studies have compared methods of hostility assessment or considered important psychosocial and cardiovascular risk factors as confounders. Furthermore, it is unknown whether all expressions of hostility carry equal risk or whether certain manifestations are more cardiotoxic.

METHODS

We assessed the independent relationship between baseline observed hostility and 10-year incident IHD in 1,749 adults of the population-based Canadian Nova Scotia Health Survey.

RESULTS

There were 149 (8.5%) incident IHD events (140 nonfatal, 9 fatal) during the 15,295 person-years of observation (9.74 events/1,000 person-years). Participants with any observed hostility had a greater risk of incident IHD than those without (p = 0.02); no such relation was found for patient-reported hostility. Those with any observed hostility had a significantly greater risk of incident IHD (hazard ratio: 2.06, 95% confidence interval: 1.04 to 4.08, p = 0.04), after adjusting for cardiovascular (age, sex, Framingham Risk Score) and psychosocial (depression, positive affect, patient-reported hostility, and anger) risk factors.

CONCLUSIONS

The presence of any observed hostility at baseline was associated with a 2-fold increased risk of incident IHD over 10 years of follow-up. Compared with patient-reported measures, observed hostility is a superior predictor of IHD.

Comparison of myocardial ischemia during intense mental stress using flight simulation in airline pilots with coronary artery disease to that produced with conventional mental and treadmill exercise stress testing

Mental stress increases cardiovascular morbidity and mortality. Although laboratory mental stress often causes less myocardial ischemia than exercise stress (ES), it is unclear whether mental stress is intrinsically different or differences are due to less hemodynamic stress with mental stress. We sought to evaluate the hemodynamic and ischemic response to intense realistic mental stress created by modern flight simulators and compare this response to that of exercise treadmill testing and conventional laboratory mental stress (CMS) testing in pilots with coronary disease. Sixteen airline pilots with angiographically documented coronary disease and documented myocardial ischemia during ES were studied using maximal treadmill ES, CMS, and aviation mental stress (AMS) testing. AMS testing was done in a sophisticated simulator using multiple system failures as stressors. Treadmill ES testing resulted in the highest heart rate, but AMS caused a higher blood pressure response than CMS. Maximal rate-pressure product was not significantly different between ES and AMS (25,646 vs 23,347, p = 0.08), although these were higher than CMS (16,336, p <0.0001). Despite similar hemodynamic stress induced by ES and AMS, AMS resulted in significantly less ST-segment depression and nuclear ischemia than ES. Differences in induction of ischemia by mental stress compared to ES do not appear to be due to the creation of less hemodynamic stress. In conclusion, even with equivalent hemodynamic stress, intense realistic mental stress induced by flight simulators results in significantly less myocardial ischemia than ES as measured by ST-segment depression and nuclear ischemia.

Mood and transient cardiac dysfunction in everyday life

Emotion in daily life may be associated with transient myocardial ischemia, ventricular tachycardia and impaired autonomic function in cardiac patients, but the precise temporal sequence is unclear. Eighty-eight patients with suspected coronary artery disease underwent 24-h electrocardiographic monitoring, and affect was measured with the Day Reconstruction Method. Thirteen patients (15%) experienced one or more episodes of ST depression or ventricular tachycardia, nine of whom provided concurrent mood data. Mood and heart rate variability were analyzed for the 15 min before, during, and 15 min after each ST depression/ventricular tachycardia episode, and were compared with control periods not associated with cardiac dysfunction. Patients reported more negative mood in the 15 min preceding cardiac dysfunction compared with control periods (P = 0.02). Heart rate increased in the 5 min before cardiac dysfunction (P = 0.005), whereas low frequency heart rate variability was reduced at onset but not before cardiac dysfunction (P = 0.007). There were not changes in high frequency heart rate variability. This small study indicates that emotional state may contribute to vulnerability of cardiac dysfunction in everyday life.

Gastric mucosal damage evaluated by transnasal endoscopy and QOL assessments in ischemic heart disease patients receiving low-dose aspirin

OBJECTIVE

Transnasal endoscopy was conducted to examine gastric mucosal damage in Japanese patients with ischemic heart disease who were receiving low-dose aspirin for preventing the onset or recurrence of cardiovascular disease.

PATIENTS AND METHODS

An endoscopist assessed gastric mucosal damage. Furthermore, the MOS 36-Item Short-Form Health Survey (SF-36(®)) and the Gastrointestinal Symptom-Rating Scale (GSRS) were used to assess the outcomes of their quality of life (QOL) and the possible presence of gastric cancer and H. pylori infection.

RESULTS

Seventy-five patients were studied; and 24 (32.0%) and 16 (21.3%) of them concurrently received antithrombotic drugs other than aspirin and antiulcer drugs, respectively. Regarding gastric mucosal damage, 15 (20.0%) and 8 (10.7%) of the patients were endoscopically diagnosed with ulcer and hemorrhagic gastritis, respectively. Furthermore, 5 patients (6.7%) were found to have esophageal or gastric cancer. The positivity rate of Helicobacter pylori (H. pylori) was 45.3%. Patients receiving low-dose aspirin showed a decreased QOL. Consequently, no significant differences were found among the groups. Regarding endoscopic findings, no differences were found in the scores of both SF-36(®) and GSRS with respect to the presence or absence of gastric ulcer, hemorrhagic gastritis, and H. pylori infection.

CONCLUSION

Transnasal endoscopy was possible to perform during the oral intake of low-dose aspirin without causing any hemorrhagic complications. Many patients with gastric mucosal lesions showed no subjective symptom, and patients receiving aspirin were strongly recommended to undergo regular transnasal endoscopy, regardless of the presence or absence of symptoms.

[Ischemic heart disease in elderly patients of behavioral type A (psychosocial and clinic functional changes, possibilities for correction)]

833 patients aged 32 to 74 years who had coronary heart disease (CHD) were examined. Psychosocial and clinicofunctional features typical for elderly people of behavioral type A and with diagnosed CHD and ways for treatment optimization and disease prophylaxis are being under consideration. We studied the clinical efficiency and influence of Anaprilin, Metoprolol, Phenazepam, non-medical methods on psychoendocrine parameters in CHD elderly patients with behavioral type A. In addition to positive changes in the anginal syndrome sleep, decreases in hot temper, irritability, anxiety, phobic manifestations, hypochondrial trends, and neurotic asthenization, increased working and social orientation were improved. During Anaprilin, Metoprolol, Phenazepam therapy, cardialgias reduced or disappered, the incidence of arrhythmia decreased. There was a reduction in the personality profile in the neurotic triad and psychoasthenia scales, the reactive anxiety diminished significantly, and levels of aldosterone, cortisol, triiodothyronine, and thyroxine in the blood decreased. Thus, supplementation of Anapriline, Metoprolol, Phenazepam to the combined therapy for patients with CHD of behavioral type A positively effected to the clinical course of the disease. Configuration of the personality profile was leveled in patients with CHD of coronary type, signs of behavioral type A decreased.

[Algorithm of anxiety-depressive disorders detection in patients with coronary heart disease in general clinical practice]

AIM

To estimate a diagnostic algorithm for anxiodepressive disorders (ADD) in coronary patients in general therapeutic practice.

MATERIAL AND METHODS

A total of 163 coronary patients were examined using Seattle, Moriski and Green, Hospital questionnaires for anxiety and depression. Patients with clinical and subclinical anxiety and/or depression by Hospital testing responded to Hamilton anxiety and depression questionnaire. An analysis of clinical, anamnestic and socioeconomic parameters was made to create a multifactor model for ADD detection in coronary patients basing on the method of multiple logistic regression.

RESULTS

A model of ADD dependence Z = -3.446 x [presence or absence of anxiety and/or depression in the past]-2.451 x [presence or absence of stress for a year] - 2.452 x [drinking alcohol or rejection of alcohol] + 0.071 x [the disease perception in percent from Seattle angina questionnaire]. In certain combination of responses (presence or absence of parameters) and digital result in 7 combinations the patients can be diagnosed to have ADD.

CONCLUSION

The diagnostic algorithm proposed helps ADD detection in coronary patients in general therapeutic practice without participation of psychotherapists and medical psychologists.

[Clinical and cost effectiveness of rehabilitation programs including physical exercises for patients with ischemic heart disease under conditions of resort and outpatient clinics]

The objective of the present study was to evaluate clinical and cost effectiveness of rehabilitation programs including long-term physical training of moderate intensity intended for the management of patients with coronary heart disease (CHD) who had undergone acute coronary events; the programs were adapted to the treatment under conditions of spa resorts, dispensaries, and outpatient clinics. It was shown that rehabilitation of patients presenting with CDH with the use of moderately intensive physical exercises during a long period enhances the effectiveness of application of the available funds due to improved clinical course of coronary heart disease, tolerance of physical load, and quality of life.

Irregular heavy drinking occasions and risk of ischemic heart disease: a systematic review and meta-analysis

Contrary to a cardioprotective effect of moderate regular alcohol consumption, accumulating evidence points to a detrimental effect of irregular heavy drinking occasions (>60 g of pure alcohol or > or =5 drinks per occasion at least monthly) on ischemic heart disease risk, even for drinkers whose average consumption is moderate. The authors systematically searched electronic databases from 1980 to 2009 for case-control or cohort studies examining the association of irregular heavy drinking occasions with ischemic heart disease risk. Studies were included if they reported either a relative risk estimate for intoxication or frequency of > or =5 drinks stratified by or adjusted for total average alcohol consumption. The search identified 14 studies (including 31 risk estimates) containing 4,718 ischemic heart disease events (morbidity and mortality). Using a standardized protocol, the authors extracted relative risk estimates and their variance, in addition to study characteristics. In a random-effects model, the pooled relative risk of irregular heavy drinking occasions compared with regular moderate drinking was 1.45 (95% confidence interval: 1.24, 1.70), with significant between-study heterogeneity (I(2) = 53.9%). Results were robust in several sensitivity analyses. The authors concluded that the cardioprotective effect of moderate alcohol consumption disappears when, on average, light to moderate drinking is mixed with irregular heavy drinking occasions.

Quality of life and emotional functioning in selected cardiovascular diseases

BACKGROUND

Numerous psychosomatic diseases, especially cardiovascular, are regarded as diseases of modern civilization. Psychological factors play a dominant role in these diseases. Among these factors we can distinguish several different types of emotional functioning and subjective estimation of patients' quality of life (QoL).

AIM

To assess the level of QoL and types of emotional functioning among patients suffering from ischaemic heart disease (IHD) and hypertension.

METHODS

A group of 160 male patients was subjected to examinations. They were divided into two groups: IHD with hypertension (120 patients) and a control group (40 healthy patients). In the examination the Emotional Control Questionnaire by Brzeziński (KKE) was applied together with Life Quality Test SF-36 and with a personal questionnaire.

RESULTS

Approximately 25% of patients had low QoL. The mean QoL was lower than in healthy subjects (p < 0.05). Also parameters of emotional functioning were significantly lower in patients than in controls (p < 0.05). Significant correlations were found between level of QoL and several types of emotional functioning (p < 0.05, p < 0.01 and p < 0.001).

CONCLUSIONS

1. Quality of life level among psychosomatic patients is significantly lower than in healthy individuals. 2. Quality of life level is closely related to emotional functioning of the studied individuals. 3. Among psychosomatic patients lower level of QoL is accompanied by higher intensity of negative emotional functioning schemes.

Acute ischemic cardiomyopathy after extreme emotional stress in a child

Ischemic cardiomyopathy is rare in children. It is usually caused by congenital anomalies of coronary arteries, coronary anomalies after coronary artery transfer, or Kawasaki disease. In recent years, a new cardiac syndrome-named "Tako-Tsubo cardiomyopathy" for the particular shape of the end systolic ventricle-has been described in adults. In the absence of coronary artery obstruction, it mimics acute myocardial infarction with chest pain and typical electrocardiography changes. Emotional or physical stress usually precedes this cardiomyopathy. At present, this entity has only been described in adults, with a strong predominance in postmenopausal women. We report a case of acute ischemic cardiomyopathy after extreme stress in a child that may share the same pathophysiology.

Usefulness of laboratory mental stress test in patients with stable coronary artery disease

BACKGROUND AND HYPOTHESIS

Many episodes of ischemia in daily life are silent occurring during sedentary activities and may be related to mental stress. In 35 patients with stable angina and positive exercise test awaiting bypass surgery, we investigated whether laboratory mental stress tests would trigger ischemia of a comparable severity to that occurring in daily life and attempted to elucidate some of the underlying mechanisms.

METHODS

All patients underwent exercise testing, personality assessment, 2-day Holter monitoring, and laboratory mental stress tests while on their usual medications.

RESULTS

Only four patients (12%) had positive mental stress test (ST depression > or = 0.1 mV). All episodes were silent and usually associated with fast heart rate (> 90 beats/min). In contrast, ambulatory ischemia was common (average duration of 51 min per 24 h), and at least one episode was recorded in 27 patients (77%) including the 4 with positive test. Patients with positive mental stress test had a higher heart rate during testing (124 +/- 24 vs. 86 +/- 16 beats/min, p < 0.01), and a shorter exercise time and time to 1 mm ST depression on cycle ergometry than those with negative mental stress test. None of the four patients were on beta blockers. There was no difference in personality inventory between the two groups. Comparisons between patients with and without positive mental stress test revealed no difference in the duration and frequency of ambulatory ischemia, or in the occurrence of silent ischemia. However, the heart rate at onset of ambulatory ischemia tended to be higher in the patients with positive mental stress test (96 +/- 9 vs. 62 +/- 43, p = 0.07). Further subgroup analysis in patients without beta blockers (4 mental stress test positive and 18 negative) showed similar results.

CONCLUSIONS

Laboratory mental stress test is a weak inducer of ischemia detected by electrocardiographic monitoring in patients with frequent ambulatory ischemia. Wall motion evaluation during mental stress test may improve sensitivity. While larger scale studies may determine its clinical role, the present study illustrated that patients with heightened heart rate response to mental stress were identified in whom beta blockers could be the drug of choice.

[Reactions of sympatho-adrenal system in patients with ischemic heart disease during emotional stress in dependence on the personality type]

The object of the study was to show the relationship between emotional stress and excitation of the sympathoadrenal system in healthy subjects and patients with coronary heart disease (CHD). Seventy eight healthy subjects and 40 CHD patients of the II-III functional class were under medical observation. Emotional tension was simulated by two methods: arithmetic under conditions of time deficit (Krepelin counting) and work in a homeostat. Homeostat simulation of emotional tension turned to be more stressogenic than Krepelin counting. In CHD patients, increase of adrenaline and noradrenaline levels was demonstrated in the condition of the emotional tension simulation. Two personality types were distinguished as type A (leaders) and type B (subordinates). The increase in the catecholamine level was especially pronounced in CHD patients of type A (leaders).

[Comparative characteristics of quality of life and physical status of patients with ischemic heart disease and aortic valve disease]

For comparison of physical status and quality of life of patients we analyzed 2 clinical groups: patients with ischemic heart disease (IHD) and aortic valve disease. Using original methodology of bringing results of questionnaire " Nottingham Health Profile " to functional classification we had a possibility to compare quality of life of patients with functional classes of physical working capacity and NYHA classification. Subjective component inserted into NYHA classification and quality of life questionnaire leads to substantial discrepancy with objective data on physical working capacity. In most cases patients of both clinical groups subjectively overestimate functional capacity of their organism. In patients with IHD most significant limitations manifest in psychic sphere of life, while in patients with aortic valve disease - in physical sphere of life, what demonstrates great effect of psychosomatic factor in development of IHD.

Influence of psychosocial work-related factors on conventional risk factors of ischemic heart disease and homocysteine in Slovenian male workers

The influence of psychosocial work-related factors on the conventional risk factors of ischemic heart disease (IHD), particularly on the lipid changes and their effect on homocysteine is studied in this paper. Employed males aged 35 to 55 with angina pectoris or a myocardial infarction (IHD group) were compared to a group of individuals without ischemic heart disease (Control Group). Psychosocial factors were assessed using a Swedish Theorell questionnaire. The IHD Group was found to be at a higher risk of IHD due to higher work demands (OR = 1.25), worse job control (OR = 1.23), frequent smoking (OR = 2.2), leadership positions (OR = 3.97), higher BMI (p = 0.059) and higher levels of triglycerides (p = 0.005) and LDL-cholesterol (OR = 1.65). The level of HDL-cholesterol was significantly lower (1.0 vs. 1.4 mmol/L, p < 0.001, OR = 1.64), while the level of C-reactive protein (9.1 vs. 1.8 mg/L) and Interleukin-6 (6.5 vs. 1.6 ng/L) was higher. Homocysteine levels showed borderline significance (p = 0.056). Our study suggests a possible influence of psychosocial work-related factors on IHD risk factors, most of all on low HDL-cholesterol. No connection was found between psychosocial factors and the homocysteine level, shown to be an IHD risk factor at lower levels of approximately 10 micromol/L.