International trends in coronary heart disease mortality, morbidity, and risk factors

Geographic variation in vascular mortality in Eurasia: spatial autocorrelation analysis of mortality variables and risk factors

The geographic variation patterns of vascular mortality and their major risk factors from 68 samples in Eurasia are described in this work. The goodness-of-fit tests and analysis of variance indicate significant differences in incidence of mortality from the studied diseases, as well as in risk factors among the various geographic regions in four age groups. Correlation analysis points out the two general tendencies for the majority of studied traits: (a) significant positive association with latitude and (b) significant negative correlation with longitude. In turn, one-dimensional correlograms showed no specific geographic pattern at least up to 3000 km for all studied variables. However, at the large geographic scale a long-distance differentiation pattern was indicated for total serum cholesterol and body mass index; regional patches--for total death rate, mortality rate from cardiovascular and ischaemic heart diseases, systolic and diastolic blood pressure; and a local patches pattern was detected for mortality rate from stroke. Two-dimensional correlograms uncovered three distinct and significant patterns of variation: (a) a north-south trend for total mortality rate, for death rate from cardiovascular and ischaemic heart diseases, for diastolic and systolic blood pressure and for body mass index; (b) a northwest-southeast pattern for mortality rate from cerebrovascular disease; and (c) local patches for total serum cholesterol.

Secular trends in coronary atherosclerosis--analysis in patients with valvular regurgitation

BACKGROUND

Between 1980 and 1989, mortality due to coronary artery disease decreased considerably in the United States, suggesting a possible decrease in the prevalence of coronary atherosclerosis. We examined this possibility in patients with valvular regurgitation who, often in the absence of angina, underwent coronary angiography before valve-replacement surgery.

METHODS

We studied 601 patients with isolated, nonischemic valvular regurgitation who were operated on between 1980 and 1989 and who had undergone preoperative coronary angiography. From the angiograms we determined the prevalence of clinically significant coronary artery disease and of multivessel disease, assessed the mean degree of stenosis, and analyzed the trends in the data over the years of the study.

RESULTS

The prevalence of coronary artery disease (35 percent in 1980-1981, 37 percent in 1982-1983, 34 percent in 1984-1985, 37 percent in 1986-1987, and 35 percent in 1988-1989; P = 0.97) did not change significantly during the study period. We found no significant change in the prevalence of multivessel disease (24 percent in 1980-1981 and 23 percent in 1988-1989, P = 0.99) or in the mean ( +/- SD) degree of stenosis (11 +/- 13 percent in 1980-1981 and 13 +/- 14 percent in 1988-1989, P = 0.07). When these measures of coronary atherosclerosis were adjusted for age and sex, there were still no significant changes over time (P = 0.39 for the prevalence of coronary artery disease, P = 0.81 for that of multivessel disease, and P = 0.57 for the mean degree of stenosis). The patients' mean total cholesterol level decreased from 219 +/- 48 mg per deciliter (5.66 +/- 1.24 mmol per liter) to 206 +/- 44 mg per deciliter (5.33 +/- 1.14 mmol per liter) between 1980 and 1989 (P = 0.04).

CONCLUSIONS

From 1980 to 1989, no significant change was observed in angiographic measures of coronary atherosclerosis in patients with nonischemic valvular regurgitation, in contrast to the marked decrease in mortality due to coronary disease in the general population. These findings suggest that the well-documented reduction in mortality due to coronary disease may not be due to a reduction in the prevalence of coronary atherosclerosis.

Family practitioners' intervention against smoking in Germany and the UK: does remuneration affect preventive activity?

The effect of different systems of remuneration on preventive activity of family practitioners (FPs) were studied. Interventions against smoking were compared in FPs' practices in Germany and the UK. Almost 800 consecutively attending patients were included in a cross-sectional survey. Smoking prevalence was remarkably similar among German and British practice attenders. Slightly more than 50% of smokers in both countries remembered an intervention against their smoking by their FP or related staff. Multiple logistic regression analysis also showed that there was no significant difference for remembered interventions between the two countries (adjusted OR 1.15 [95%-Cl 0.6, 2.2]). The structure of interventions employed was similar in both countries. Most British and German ex-smokers denied that their FP had made an important contribution to their giving up smoking. There is evidence that, under capitation, FPs concentrate their activities on patients who are more at risk. Overall, however, the economic structure does not seem to influence the core of preventive behaviour of FPs to any great extent. Smoking cessation efforts in Family Practice need to be improved in both countries.

Changed incidence and case-fatality rates of first-ever stroke between 1970 and 1993 in Tartu, Estonia

BACKGROUND AND PURPOSE

The incidence of stroke has stabilized or increased in several developed countries recently, but few data about the trends are available from Eastern Europe. The study was designed to evaluate the possible changes of stroke incidence in Estonia.

METHODS

A population-based stroke registry was conducted in Tartu during 1991 through 1993 (mean population, 110,631) to compare it with the study of 1970 through 1973 (population, 90,459). The majority of stroke patients were recorded prospectively, and most were hospitalized and evaluated by a neurologist. All available medical records were reviewed. Only first-ever stroke cases were registered.

RESULTS

A total of 667 patients in 1970 through 1973 and 829 patients in 1991 through 1993 were recorded. The total annual incidence per 100,000 rose from 221 to 250 (P = .0173). The total rate for men increased nonsignificantly from 183 to 209 and for women from 258 to 284. Significant increases were observed for men aged 50 to 59 years and for women aged 50 to 69 years; for persons over 70 years, the rates slightly declined. The case-fatality rate at 1 month declined significantly, from 49% to 30%.

CONCLUSIONS

A remarkable increase in the incidence and decline in the case-fatality rate of first-ever stroke was observed in Tartu, Estonia. The increase of incidence for those younger than 70 years could be due to the increased prevalence of risk factors. The decline in case fatality could theoretically be related to better management of secondary complications.

Alcohol, coronary disease, and hypertension

Disparities in the relationships between alcohol consumption and various cardiovascular conditions are now evident, with complex interrelationships between conditions. An inverse relationship of alcohol use to coronary heart disease is supported by many population studies. Interpretation of these data as a protective effect of alcohol against coronary disease is strengthened by plausible mechanisms. Although some experimental data suggest the hypothesis that wine, in particular, has additional protective benefit, prospective studies show no consensus on this point. Strong, consistent epidemiologic data support a relationship of heavier drinking to hypertension. Intervention studies show a pressor effect of alcohol, which appears and regresses within several days, but a mechanism has not yet been established. As with most aspects of alcohol and health effects, the data do not suggest monotonic relationships of alcohol with these conditions. Thus, amount of alcohol taken is a crucial consideration. Advice to concerned persons needs to take into account individual factors in drinkers or potential drinkers.

An update on coronary risk factors

Epidemiologic research continues to produce additional independent risk factors, including small dense LDL, Lp(a), isolated systolic hypertension, the insulin-resistance syndrome, leucocyte count, plasma fibrinogen, homocystinemia, and sleep disturbance. Alcohol in moderation appears protective. Because the hazard posed by any particular risk factor is markedly influenced by other metabolically linked risk factors with which it tends to cluster, multivariate risk assessment provides a substantially better risk estimate than that based on single risk factors.

Estrogenic soybean isoflavones and chronic disease Risks and benefits

Many edible plants contain natural estrogens called phytoestrogens. These compounds possess mixed estrogen agonist-antagonist properties that are organ-specific in vivo. We have focused on estrogenic soybean isoflavones because of their potential extensive dietary availability. In this article, we review the clinical and experimental evidence for the possible benefits and risks of ingestion of estrogenic isoflavones throughout the life span, and highlight areas needing further elucidation.

The epidemiologic transition to chronic diseases in developing countries: cardiovascular mortality, morbidity, and risk factors in Seychelles (Indian Ocean). Investigators of the Seychelles Heart Study

The occurrence of cardiovascular diseases (CVD) and related risk factors was evaluated in Seychelles, a middle level income country, as accumulating evidence supports increasing rates of CVD in developing countries. CVD mortality was obtained from vital statistics for two periods, 1984-5 and 1991-3. CVD morbidity was estimated by retrospective review of discharge diagnoses for all admissions to medical wards in 1990-1992. Levels of CVD risk factors in the population were assessed in 1989 through a population-based survey. In 1991-93, standardized mortality rates were in males and females respectively, 80.9 and 38.8 for cerebrovascular disease and 92.9 and 47.0 for ischemic heart disease. CVD accounted for 25.2% of all admissions to medical wards. Among the general population aged 35-64, 30% had high blood pressure, 52% of males smoked, and 28% of females were obese. These findings substantiate the current health transition to CVD in Seychelles. More generally, epidemiologic data on CVD mortality, morbidity, and related risk factors, as well as similar indicators for other chronic diseases, should more consistently appear in national and international reports of human development to help emphasize, in the health policy making scene, the current transition to chronic diseases in developing countries and the subsequent need for appropriate control and prevention programs.

Factors affecting the regulation of apo B secretion by liver cells

The concentration of apo B is an important risk factor for atherosclerosis, and thus its reduction is associated with a reduction in CHD mortality. In order to reduce apo B concentrations effectively, we must understand how plasma apo B concentration is regulated. Apo B is synthesized, assembled, and secreted by the liver, controlling this process will reduce the number of particles that eventually enter the plasma compartment. The assembly of apo B into a VLDL particle is a complex process which occurs through several stages: peptide synthesis, translocation, accumulation of lipid, and transport through the secretory pathway. Multiple control points regulate the synthesis and secretion of apolipoproteins. Modulation of transcription, translation and intracellular degradation represent independent regulatory mechanisms. The ability of the lipoprotein to bind cotranslationally to lipid appears to be crucial to the formation of a secreted particle. This process may be regulated solely by MTP, or may be modified by the activity of the lipid-synthesizing enzymes. A great deal of evidence supports the role of TG and CE synthesis, although the relative importance of these two lipids is a source of major controversy. In summary, all the lipoprotein components can be limiting for apo B and VLDL synthesis when their availability is substantially decreased. The rate-limiting component in vivo has still not been identified. By understanding how lipoprotein synthesis and assembly are regulated, it should become possible to design new ways of altering these processes in a beneficial manner.

Public health, cardiovascular disease and molecular biology

Rapid developments in molecular biology provide the tools to search for genetic markers of coronary heart disease. Already the angiotensin converting enzyme and the angiotensinogen genes have been implicated in myocardial infarction and hypertension. However, common conditions such as coronary disease raise special problems for genetics both in selection of suitable subjects and the use of informative genetic methods. Traditionally genetics has focused on the family; now it must broaden that view to identify markers that are relevant to the general community. The magnitude and complexity of the problem demands collaboration between epidemiologists, physicians, geneticists and laboratory scientists. This paper proposes a two stage approach to the genetics of coronary heart disease, beginning with affected relative pair linkage studies using the new generation gene maps to define chromosomal regions of interest. The thorough and systematic search using gene maps also offers the possibility of defining genetic markers of "hidden" coronary risk factors. In the second stage, candidate genes within these regions are examined in case-control association studies to identify simple markers that divide the population into groups with contrasting risk of coronary disease. It is important that families and cases are representative of the general population, otherwise the predictive value of the new genetic markers will be in doubt. In particular, genetic analyses should avoid the potential bias resulting from the exclusion of cases of sudden and unexpected coronary death.

Evaluating the effectiveness of dyslipidemia control strategies

While cost-effectiveness analyses of anti-hyperlipidemia programs featuring drug treatment suggest that the best use of public dollars is to delay treatment until an individual develops coronary heart disease, a comprehensive hyperlipidemia treatment policy must take a broader perspective. The high case-fatality rates of patients exhibiting first manifestations of coronary heart disease, the limited population impact of interventions aimed solely at high risk groups, the cost of testing to identify the high risk segment of the population, the social origins of the behavioral risk factors for coronary heart disease, and the perspective of the individual must also be considered. Available data suggest that the best public policy to control the burden of heart disease is one with two components: On the one hand, all individuals without clinically manifest heart disease would be encouraged to adopt healthy behaviors without an attempt to sort the population into 'high' and 'not high' risk groups. On the other hand, the risk factors of individuals who already have coronary heart disease would be treated aggressively with a case-management system of follow-up. The data that support this conclusion are presented in this paper.

Community social change and mortality

This paper first reviews the types of explanations that have been used in analyzing unequal distribution in coronary heart disease among different groups and changes in prevalence over time. The explanations have mostly focused on the individual: individual behaviors, personalities, stressors, or social ties. It is suggested here that a shift in focus to community-level characteristics may also aid in understanding changes in mortality. Data are presented from Roseto, PA--a town that became known in the 1960's for its strong Italian traditions and very low mortality from myocardial infarction and that subsequently experienced a sharp rise in mortality--and from the adjacent comparison town of Bangor. Data collected over several decades--in some cases as far back as 1925--on marriages, population composition, organizational memberships, voting patterns, and social class indicators suggest that important community changes that accelerated significantly in the 1960's coincided with and may help to explain Roseto's loss of protection from coronary heart disease deaths after 1965.

Cardiovascular disease mortality in Belgrade: trends from 1975-89

STUDY OBJECTIVE

To determine trends in cardiovascular disease mortality.

DESIGN

This was a descriptive study analysing mortality data.

SETTING

Belgrade, Yugoslavia.

PARTICIPANTS

The population of Belgrade in the age group 30-69 years was studied (about 760,000 inhabitants).

MEASUREMENTS

Mortality rates were standardised directly using those of the "European population" as the standard, and regression analysis was undertaken.

MAIN RESULTS

Between 1975 and 1989 "all causes" mortality increased by 27% (95% confidence interval 18.5, 35.9) in men and by 19% (11.6, 27.1) in women. The increase in cardiovascular disease mortality was 7% (1.7, 11.5) for men and 4% (0.2, 7.8) for women. Mortality from ischaemic heart disease fell in both sexes by 32% (23.0, 41.0), but mortality from other heart diseases rose by 31% (22.0, 40.2) in men and 25% (16.2, 33.0) in women. In men the death rate for cerebrovascular disease increased by 37% (27.8, 46.8), but in women the rate fell by 0.4% (-0.8, 1.6). Mortality from the observed causes of death was higher in men than in women.

CONCLUSION

Cardiovascular mortality trends in Belgrade are similar to those in most eastern European countries. If the distribution of cigarette smoking and a "rich" diet in the Belgrade population is taken into account, a considerable decline in cardiovascular mortality trends cannot be expected in the near future.

Physical activity and 23-year incidence of coronary heart disease morbidity and mortality among middle-aged men. The Honolulu Heart Program

BACKGROUND

The purpose of the study was to examine the association between physical activity and 23-year incidence of coronary heart disease morbidity and mortality. This cohort study continues to follow 8006 Japanese-American men who were 45 to 68 years of age and living on Oahu, Hawaii, in 1965, for the development of coronary heart disease morbidity and mortality.

METHODS AND RESULTS

The Framingham physical activity index was calculated by summing the product of average hours spent at each activity level and a weighting factor based on oxygen consumption. Study subjects were divided into tertiles of physical activity index at baseline. Relative risks and 95% confidence intervals (CI) for incidence of coronary heart disease morbidity and mortality were obtained using the Cox model. After age adjustment and using the lowest physical activity index tertile as a reference group, the relative risk for coronary heart disease incidence for the highest tertile of physical activity was 0.83 (CI, 0.70 to 0.99). After adjusting for age, hypertension, smoking, alcohol intake, diabetes, cholesterol, and body mass index, the relative risk was 0.95 and CI included 1 (CI, 0.80 to 1.14). For coronary heart disease mortality, the age-adjusted relative risk was 0.74 (CI, 0.56 to 0.97) and 0.85 (CI, 0.65 to 1.13) after risk factor adjustment.

CONCLUSIONS

The results suggest that the impact of physical activity index on coronary heart disease is mediated through its effects on hypertension, diabetes, cholesterol, and body mass index. These findings support the hypothesis that physical activity is inversely associated with coronary heart disease morbidity and mortality and suggest that physical activity interventions in middle-aged men, by improving cardiovascular risk factor levels, may have significant public health implications in the prevention of coronary heart disease.

Blood pressure measurement error: its effect on cross-sectional and trend analyses

The measurement of blood pressure in epidemiological studies is difficult to standardize between centres in multi-centre studies and between repeat surveys over time. The use of standard mercury sphygmomanometers is common but especially prone to measurement error in terms of departure from the protocol and variation in measurement technique. Data from Australia's cardiovascular risk factor prevalence surveys on 21 independent populations, distributed geographically and temporally, has been examined to assess the effect of these errors on cross-sectional and trend analyses. The examination showed that last digit preference for zero may inflate estimates of proportions having high blood pressure. A tendency to record identical duplicate measurements could contribute 0.85 mmHg to time trends or geographic differences in mean systolic blood pressure (but not diastolic blood pressure). Epidemiological studies for geographic and trend differentials in systolic blood pressure need to be mindful of these effects in their analysis. There was some evidence of deterioration in data quality during data collection but no evidence that observers were influenced in their recording practice by observable respondents' characteristics. Training procedures for blood pressure measurement are of critical importance and adherence to the measurement protocol should be continuously monitored during data collection to ensure comparability of results.

Avaliação em saúde: limites e perspectivas

É realizada discussão sobre a avaliação em saúde no que diz respeito ao seu objeto, atributos, enfoques teóricos e desenhos, a partir da revisão da literatura sobre o tema. São relacionadas possíveis técnicas para avaliação da eficácia, efetividade, cobertura e qualidade técnico-científica dos serviços de saúde, além da satisfação dos usuários. Os desenhos da chamada "pesquisa avaliativa" são comparados com aqueles da epidemiologia. A diversidade terminológica, insuficiências e inadequações de alguns métodos e técnicas dominantes na literatura específica são identificados como problemas a serem superados. É também discutida a incipiente incorporação da prática da avaliação no processo concreto de gestão dos serviços de saúde no nosso meio e relacionadas as possibilidades de utilização das informações registradas rotineiramente nas unidades sanitárias para o processo de avaliação. Por fim, são identificadas as necessidades de desenvolvimento metodológico para avaliação dos recentes projetos de reorganização de práticas de saúde em distritos sanitários e sistemas locais de saúde e apontadas perspectivas nessa direção.

Eating fat or being fat and risk of cardiovascular disease and cancer among women

This article first reviews the relationship between intake of saturated fat and cholesterol and atherosclerosis; then the relationship between fat intake, obesity, and disease; and finally, some of the determinants of obesity and weight gain. The percentage of saturated fat and cholesterol in the diet is the major determinant of atherosclerosis and coronary heart disease among populations. In addition, fat intake is directly related to obesity. The degree of obesity is a major determinant of blood glucose and insulin, high-density-lipoprotein cholesterol, and triglycerides. Weight gain, especially after adolescence, and high fat intake may contribute, to a greater extent, to metabolically active intra-abdominal fat and risk of disease. Fat in diet, weight gain, or obesity may play an important role in sex-steroid hormone metabolism. Hormonal changes may contribute to an increased risk of breast cancer. The risks associated with eating fat may be related to the time of development of obesity (i.e., weight gain) and the balance between effects on sex-steroid hormone metabolism and insulin-glucose metabolism.

The role of lifestyle factors in the etiology of stroke. A population-based case-control study in Perth, Western Australia

BACKGROUND AND PURPOSE

We sought to examine risk factors for all strokes and for ischemic stroke and primary intracerebral hemorrhage separately.

METHODS

This was a population-based case-control study. Each case subject meeting World Health Organization criteria for stroke (n = 536) from a population-based register of acute cerebrovascular events compiled in Perth, Western Australia, in 1989 to 1990 was matched for age and sex with up to five control subjects drawn from the same geographical area. Objective confirmation of the type of stroke was available from computed tomography, magnetic resonance imaging, or necropsy for 86% of the case subjects. Data on medical history and lifestyle factors were collected from case and control subjects by interview of the subject or a proxy informant.

RESULTS

Current smoking, consumption of meat more than four times weekly, and a history of hypertension or intermittent claudication were each associated with increased risk in multivariate models for all strokes and for all first-ever strokes. Consumption of 1 to 20 g/d alcohol in the preceding week was associated with a significant reduction in the risk of all strokes, all ischemic strokes, and of primary intracerebral hemorrhage, while eating fish more than two times per month appeared to protect against first-ever stroke and against primary intracerebral hemorrhage. Diabetes mellitus was associated with a significantly increased risk of ischemic stroke but a decreased risk of hemorrhagic stroke.

CONCLUSIONS

Risk factors for ischemic and hemorrhagic stroke are not exactly the same. Changes in lifestyle relating to tobacco and diet might make important contributions to further reductions in the incidence of stroke.

Coronary heart disease case fatality in four countries. A community study. The Acute Myocardial Infarction Register Teams of Auckland, Augsburg, Bremen, FINMONICA, Newcastle, and Perth

BACKGROUND

Community-based registers participating in the MONICA Project of the World Health Organization show markedly different attack and death rates of coronary heart disease. This variation is a function of both the incidence and case fatality occurring within countries. The contribution of case fatality to the international variation in coronary heart disease mortality rates is not well understood.

METHODS AND RESULTS

The register data from eight study populations--Augsburg and Bremen in Germany, Auckland in New Zealand, Perth and Newcastle in Australia, and North Karelia, Kuopio, and Turku/Loimaa in Finland--were compared. All patients with definite myocardial infarction or coronary death aged 35 to 64 years occurring in the study populations in 1985 through 1989 are the basis for the case fatality calculations by different definitions: 28-day case fatality for all cases, for hospitalized cases, and for hospitalized 24-hour survivors; out-of-hospital case fatality; and 24-hour case fatality for hospitalized cases. Differences in case fatality were much smaller than differences in attack and mortality rates in these populations. About two thirds of deaths occurred before the patients reached a hospital. The 28-day case fatality ranged from 37% for men in Perth to 58% for women in Augsburg. Among those who reached the hospital alive, 28-day case fatality was 13% to 27% for men and 20% to 35% for women. In those who survived 24 hours from the onset of symptoms, 28-day case fatality was 8% to 17% for men and 12% to 26% for women.

CONCLUSIONS

Differences in case fatality were not associated with differences in coronary mortality rates between these populations. As most deaths occurred before reaching a hospital, opportunities for reducing case fatality through improved hospital care are limited. This emphasizes the primary role of prevention in reducing coronary death rates.

Prevalence of coronary heart disease in the rural population of Thiruvananthapuram district, Kerala, India

To establish the prevalence, with 95% confidence limits, of some of the indicators of coronary heart disease in the rural population of Thiruvananthapuram district, Kerala state, India, we did a field survey on a cluster sample with probability proportionate to size (PPS sample) of 500 households from five villages. Altogether the sample consisted of 1253 individuals who were more than 25 years of age, of which 1130 responded (90%). The survey instruments included the Malayalam translation of the Rose questionnaire, a standard 12-lead electrocardiogram with a battery operated portable electrocardiograph machine, blood pressure measurements using a mercury sphygmomanometer, and routine anthropometric measurements. The prevalence rates estimated were: (a) ECG changes suggestive of coronary heart disease, 36/1000 (95% C.L., 18, 55), (b) Rose questionnaire angina, 48/1000 (95% C.L. 35, 62), (c) definitive evidence of coronary heart disease, 14/1000 (95% C.L., 7, 21), (d) possible evidence of coronary heart disease, 74/1000 (95% C.L., 55, 93). Prevalence of major risk factors were, (a) hypertension by the WHO criteria, 179/1000 (95% C.L., 137, 221), (b) smoking, 219/1000 (95% C.L., 151, 287), (c) diabetes, 40/1000 (95% C.L., 17, 63), (d) obesity, 55/1000 (95% C.L., 6, 104). We have found that objective criteria indicate a lower prevalence of coronary heart disease in rural Thiruvananthapuram district when compared to studies from urban centres in India, but the prevalence of angina by Rose questionnaire is greater.

Recent trends in sex mortality ratios for adults in developed countries

This paper analyzes changes in sex mortality ratios between 1979 and 1987 for adults in 23 developed countries. (A sex mortality ratio is the ratio of male to female death rates.) Previous analyses have shown that during the mid-twentieth century sex mortality ratios increased for all adult age groups. During the 1980s sex mortality ratios continued to increase for 25-34 year olds, but showed mixed trends for other adult age groups. For example, for older adults aged 55-64, sex mortality ratios increased in Southern and Eastern European countries and Japan, but sex mortality ratios decreased in Northern European and Anglophone countries. Trends in several causes of death contributed to these trends in sex mortality ratios. For example, for 25-34 year olds, increases in men's suicide rates and HIV or AIDS mortality contributed to the increases in sex mortality ratios. For older adults, it was hypothesized that decreasing sex differences in cigarette smoking in recent decades would result in decreasing sex differences in lung cancer and ischemic heart disease mortality during the 1980s. The predicted decrease in sex differences in lung cancer mortality was observed in many countries; women had more unfavorable lung cancer mortality trends than men in the Anglophone countries and Northern and Central Western European countries. In contrast, very little evidence was found for the predicted decrease in sex differences in ischemic heart disease. The paper presents additional data concerning the contributions of trends in specific causes of death to changes in sex mortality ratios and briefly reviews evidence concerning probable causes of the observed mortality trends. It appears that recent trends in sex mortality ratios have been influenced by changing sex differences in smoking and a variety of additional factors, such as the effects of improvements in health care interacting with inherent sex differences in vulnerability to ischemic heart disease.

Correlation between mortality trends of ischaemic cardiopathy and some nutritional factors in Spain 1968-1986

After describing the evolution of mortality from ischaemic cardiopathy (IC) in Spain from 1951 to 1986, which is tending to stabilize in some age groups, and from cerebrovascular accidents (CVA), which is clearly declining, an attempt is made to relate these developments to the prevalence of the main risk factors (hypertension, cholesterol, tobacco) associated with IC and CVA. Certain advances, though of a limited number, have been made in recent years in the control of arterial hypertension in Spain, although campaigns on a national scale as in other countries have not been carried out. Regarding alimentary factors, there is an obvious increase in the consumption of food rich in proteins and animal fats, abandoning to a great extent the traditional "Mediterranean diet", with health care action being limited to the improvement of nutrition education of the public. Furthermore, the consumption of tobacco has been increasing in Spain during the study period in spite of health legislation in force in recent years. It is therefore deduced that there is no obvious relationship between mortality due to IC and CVA and the prevalence of the main risk factors associated with these diseases, especially when taking into account that preventive actions on a public health level have been very limited.