Family history as an independent risk factor for incident coronary artery disease in a high-risk cohort in Utah

Frequency and Clinical Impact of Family History of Coronary Artery Disease in Patients with Vasospastic Angina

BACKGROUND

Family history (FH) of coronary artery disease (CAD) [FH-CAD] is a well-known risk factor for atherosclerotic CAD. However, FH-CAD frequency in patients with vasospastic angina (VSA) remains unknown, and the clinical characteristics and prognosis of VSA patients with FH-CAD are unclear. Therefore, this study compared FH-CAD frequency between patients with atherosclerotic CAD and those with VSA and examined the clinical characteristics and prognosis of VSA patients with FH-CAD.

METHODS

Coronary angiography and spasm provocation tests (SPT) were used to investigate chest pain of coronary artery origin in patients classified into atherosclerotic CAD (362 cases), VSA (221 cases; positive for SPT) and non-VSA (73 cases; negative for SPT) groups, with FH-CAD being defined. In the VSA group, flow-mediated vasodilation (FMD) and nitroglycerin-independent vasodilation (NID) via brachial artery echocardiography and clinical symptoms in the groups with and without FH-CAD were checked, with Kaplan-Meier curves revealing major adverse cardiovascular events (cardiac death and rehospitalisation for cardiovascular disease) between the two groups.

RESULTS

The atherosclerotic CAD group had a significantly lower FH-CAD frequency (12%, p = 0.029) than the VSA (19%) and non-VSA groups (19%). FH-CAD was more common in females in the VSA and non-VSA groups than in the atherosclerotic CAD group (p < 0.001). Nonpharmacological treatment for CAD in FH-CAD was more common in the atherosclerotic CAD group (p = 0.017). In the VSA group, FH-CAD tended to be more common in females (p = 0.052). Although no differences in FMD of the brachial artery were observed between the groups, the FH-CAD (+) group had significantly higher NID than the FH-CAD (-) group (p = 0.023). Kaplan-Meier's analysis revealed a similar prognosis between the two groups, and other clinical characteristics did not differ.

CONCLUSION

Patients with VSA have a higher FH-CAD frequency than those with atherosclerotic CAD, especially in females. Although FH-CAD may affect vascular function in patients with VSA, its effect on the severity and prognosis of VSA appears to be minimal. FH-CAD and its confirmation may assist in CAD diagnosis, especially in female patients.

The Risk Factors of Acute Coronary Syndrome in Young Women: A Systematic Review and Meta-Analysis

BACKGROUND

Acute coronary syndrome (ACS) has been one of the leading causes of mortality in the world. Despite common understanding regarding ACS as an older population's or man's disease, the number of young women affected by this condition is increasing. Many studies have assessed the risk factors of ACS, but only a few studies focused on this subpopulation. Therefore, this systematic review and meta-analysis aim to evaluate the risk factors predisposing to ACS in the young women population.

METHODS

Nine online databases were screened from the date of inception to September 2021, where the acquired studies were evaluated using the PRISMA statement. The inclusion criteria were a case control study with women age cut-off of <50 years. The risk factors of acute coronary syndrome were analyzed using a random-effect model, expressed as summary statistics of odds ratio (OR) for categorical variable and standard mean difference (SMD) for continuous data with normal distribution, with 95% confidence interval (CI). Quality assessment was conducted using the STROBE statement.

RESULTS

Seven studies with the total of 7042 patients met the inclusion criteria of this metaanalysis. Diabetes mellitus, high BMI, obesity, hypercholestrolemia, hypertension, smoking, and family history significantly increased acute coronary syndrome risk in young women. Other risks such as heavy alcohol consumption, oral contraceptive use, and postmenopausal state were associated with higher risk of ACS.

CONCLUSION

The independent risk factors which are strongly related to ACS in young women were diabetes mellitus, hypertension, and hypercholesterolemia with odd ratios of 6.21, 5.32, and 4.07. Other risk factors which may be associated with an increased risk of ACS in young women were heavy alcohol consumption, oral contraceptive use, and postmenopausal state. Health promotion and effective intervention on this specific population regarding these risk factors can decrease young female cardiovascular morbidity and mortality as well as improved quality of life of women.

Relationship between serum high sensitivity C-reactive protein with angiographic severity of coronary artery disease and traditional cardiovascular risk factors

Serum high-sensitivity C-reactive protein (hs-CRP) is predictive of coronary artery disease (CAD). The aim of this study was to examine the possible association of hs-CRP with presence and severity of CAD and traditional CAD risk factors. This case-control study was carried out on 2,346 individuals from September 2011 to May 2013. Of these 1,187 had evidence of coronary disease, and were subject to coronary angiography, and the remainder were healthy controls (n = 1,159). Characteristics were determined using standard laboratory techniques and serum Hs-CRP levels were estimated using enzyme-linked immunosorbent assay (ELISA) kits, and severity of CAD was assessed according to the score of obstruction in coronary artery. Serum hs-CRP levels were higher in those with severe coronary disease, who had stenosis ≥ 50% stenosis of at least one coronary artery (all p < 0.001 vs. individuals in healthy control), and correlated significantly with the score for coronary artery disease (all p < 0.01). After adjustment for conventional risk factors, regression analysis revealed that smoking habits, fasting blood glucose, total cholesterol, high-density lipoprotein, hs-CRP, blood pressure, anxiety, dietary intake of vitamin E, and cholesterol remained as independent determinants for angiographic severity of CAD. The area under the receiving operating characteristic (ROC) curve for serum hs-CRP was 0.869 (CI 95% 0.721-0.872, p < 0.001). The optimal values for the cut-off point was a serum hs-CRP of 2.78 mg/l (sensitivity 80.20%, specificity 85%) to predict severity of CAD. Increased serum hs-CRP levels are significantly associated with angiographic severity of CAD, suggesting its value as a biomarkers for predicting CAD.

Age threshold for proper definition of premature coronary artery disease in males

BACKGROUND

There is no universally accepted definition for the cut point age before which atherosclerosis is considered "premature." This is a retrospective study aimed to utilize the medico legal autopsy information for finding a proper definition of the age threshold of premature atherosclerosis in males.

OBJECTIVES

This work aimed to utilize autopsy reports data that were issued at Jordan University Hospital to evaluate age-related differences in the distribution of coronary atherosclerotic and myocardial lesions and the determination of the age threshold at which such differences became apparent in male deaths. Such a threshold might provide a proper definition for premature atherosclerosis and premature sudden atherosclerotic cardiac death. At the same time, the meaning of a reference age for mature atherosclerotic death incidents could be elucidated.

METHODS

A total of 1139 male autopsy reports with sudden coronary atherosclerotic death were reviewed.

RESULTS

There is an overall decreasing trend in the prevalence of coronary thrombosis with age, where the prevalence of coronary thrombosis was more common in younger age groups and constitutes 59.9% of cases in the age groups less than 45 years in comparison to 42.7% of cases in the ages more than 65 years. The same trend was noticed for the prevalence of cases without evident myocardial fibrosis. On the other hand, the trend was increasing for stenosis without apparent thrombosis and for myocardial fibrosis. In spite of that, the detailed pattern of the prevalence of these pathologies with age did not show a steady, and a continuous change through the whole spanned age groups. Instead, two distinct phases were observed, the first phase represents the cases less than 49 years of age and the second phase represents the cases more than the age of 54 and the age group between 50/54 is what we called the "turn-interval."

CONCLUSION

sThe "turn-interval" was considered as the scientific basis to define the age threshold that differentiates the premature atherosclerotic coronary diseases. Accordingly, it was proposed that male premature coronary artery diseases constituted the cases suffering from the heart attack, or died as a result of cardiac attacks below the age of 49, and the mature disease that affects people who is older than 54 years old.

Coronary artery calcium findings in asymptomatic subjects with family history of premature coronary artery disease

Background

To evaluate the frequency of positive coronary arteries calcium (CAC) scores in a unique population of asymptomatic first degree relatives (FDRs) of patients with angiographically confirmed early onset of coronary artery disease (CAD) and to assess their association with carotid ultrasound findings and other cardiovascular risk factors.

Method and results

We scanned, using 64-slice multi-detector computed tomography, 57 asymptomatic FDRs (47 ± 9 years old; 44% male, 56% female), out of the 111 FDRs previously phenotyped for cardiovascular (CV) risk factors. The controls were 616 individuals (57 ± 10 years old; 76% male, 24% female) with no family history of cardiovascular disease, chest pain or diabetes selected out of the 3500 subjects scanned between 2002 and 2007. FDRs had higher risk of abnormal CAC scores compared to controls; odds ratio (OR) for the 75^th percentile was 1.96 (95% CI 1.04 – 3.67, p < 0.05).

Conclusion

The frequency of abnormal CAC scores is two-fold higher in asymptomatic FDRs than in controls. CAC scan provides additional information on CV risk assessment in asymptomatic FDRs, particularly for those in the intermediate risk category.

Clinical trial registration

NCT00387595

Determinants of brachial-ankle pulse wave velocity in a Japanese population: a cohort study

Arterial stiffness is one of the biggest predictors of coronary heart disease (CHD). We evaluated whether brachial-ankle pulse wave velocity (baPWV) and augmentation index (AI) are correlated with risk factors of CHD. All of the 528 participants (270 males and 258 females) in this study were healthy workers aged from 36 to 69 (mean age: 47.9 ± 8.1 years). The Framingham Risk Score (FRS) showed a good correlation with baPWV (r = 0.53, p < 0.01), indicating that FRS is also applicable as an index of arterial stiffness in Japanese people. Blood pressures were well controlled in patients with medical treatment for hypertension; however, vessels remained relatively still stiff, whereas the AI was considerably low. Multivariate linear regression analysis showed that factors of such as FRS, body mass index, alcohol consumption and AI P75 were significantly correlated with baPWV.

Genetics of coronary artery disease in the 21st century

Coronary artery disease (CAD) is still the number-one killer in the world, and clinical trials indicate that it is preventable. Mortality and morbidity can be reduced by at least 30% to 40% by treating known risk factors. Genetic susceptibility is claimed to account for 50% of predisposition. The challenge of preventing CAD in this century, as claimed by some investigators, will require a more comprehensive prevention and treatment of environmental and genetic risk factors. Part of that challenge has been met by genome-wide association studies, which have identified 36 genetic variants with increased risk for CAD. All of these genetic variants have reached genome-wide significance (5 × 10(-8) ) and replicate in independent populations with large sample sizes. More than 50% of these variants occur in >50% of the population, with 10 occurring in >75% of the population. The challenge and the opportunity lie in the observation that >66% of these risk variants do not mediate their risk through known conventional risk factors. These results suggest that genetic predisposition for CAD is conferred by common DNA variants and many factors contributing to the pathogenesis of CAD are yet to be determined. Comprehensive prevention of CAD will most likely require combating genetic and environmental risk factors. We are on the cusp of genetic screening, and new therapeutic targets are becoming available to manage both genetic and environmental risk factors for CAD.

9p21 and the Genetic Revolution for Coronary Artery Disease

BACKGROUND

It has long been recognized that 50% of the susceptibility for coronary artery disease (CAD) is due to predisposing genetic factors. Comprehensive prevention is likely to require knowledge of these genetic factors.

CONTENT

Using a genomewide association study (GWAS), the Ottawa Heart Genomic Study and the deCODE group simultaneously identified the first genetic risk variant, at chromosome 9p21. The 9p21 variant became the first risk factor to be identified since 1964. 9p21 occurs in 75% of the population except for African Americans and is associated with a 25% increased risk for CAD with 1 copy and a 50% increased risk with 2 copies. Perhaps the most remarkable finding is that 9p21 is independent of all known risk factors, indicating there are factors contributing to the pathogenesis of CAD that are yet unknown. 9p21 in individuals with premature CAD is associated with a 2-fold increase in risk, similar to that of smoking and cholesterol. Routine genetic testing will probably remain controversial until a specific treatment is developed. Over a period of 5 years, however, GWASs have identified 30 genetic variants for CAD risk, of which only 6 act through the known risk factors.

SUMMARY

The 9p21 variant has now been established as an independent risk factor for CAD and, along with the additional 29 risk genetic variants recently identified, is likely to provide the thrust for genetic testing and personalized medicine in the near future.

Family history of myocardial infarction predicts incident coronary heart disease in postmenopausal women with diabetes: the Women's Health Initiative Observational Study

BACKGROUND

Diabetes is a risk factor for coronary heart disease (CHD) but CHD does not occur in all diabetic individuals. The goal of this study was to assess the relationship between family history of myocardial infarction (MI) and incident CHD in diabetic postmenopausal women.

METHODS

We conducted a prospective cohort study among 2642 diabetic postmenopausal women without CHD at baseline in the Women's Health Initiative Observational Study. Family history was defined as a proband report of MI in first-degree relatives. Incident CHD was defined as non-fatal MI, coronary revascularization, or CHD death.

RESULTS

During 7.3 ( +/- 1.8) years of follow-up, 14.3% of the participants had incident CHD. The risk of incident CHD was 50% higher (HR = 1.50, 95% CI: 1.20-1.87, p = 0.0003) in those with a family history of an MI in at least one first-degree relative, and 79% higher (HR = 1.79, 95% CI: 1.36-2.35, P < 0.0001) if two or more first-degree relatives had an MI, compared to participants without a family history, after adjustment for covariates. The CHD risk increased with elevated systolic blood pressure (SBP) (HR = 1.01, 95% CI: 1.003-1.02, p = 0.001) but decreased with elevated diastolic BP (HR = 0.98, 95% CI: 0.97-0.999, p = 0.005) and with two or more episodes per week of physical activity (HR = 0.70, 95% CI: 0.52-0.93, p = 0.02).

CONCLUSIONS

The results suggest that a family history of MI predicts CHD in diabetic postmenopausal women. Close attention should be paid to BP control and physical activity in these women.

Subclinical atherosclerosis in subjects with family history of premature coronary artery disease

BACKGROUND

First-degree relatives (FDRs) of subjects with early onset of coronary heart disease (CHD) have higher risk of developing cardiovascular disease. We verified early CHD by angiography in index patients and extensively phenotyped their FDRs to investigate the relationship of traditional and nontraditional cardiovascular risk factors to carotid ultrasound measures of subclinical atherosclerosis.

METHODS AND RESULTS

B-mode carotid ultrasound was used to assess the combined intimamedia thickness and plaque burden in 111 FDRs (65 men, 44.4 +/- 11 and 46 women, 44.7 +/- 13 years old) of 82 index patients (men <50 and women <60 years of age at the time of the event). The biochemical and anthropometrical characteristics of the FDRs were compared with those of healthy controls matched for sex, age, ethnicity, and body mass index. First-degree relatives had increased average total thickness (a combined measure of intimamedia thickness and plaque) compared to controls (0.76 mm, interquartile range [IQR] 0.69-1.01 vs 0.69 mm, IQR 0.60-0.88, P < .001) even after adjusting for age, total cholesterol-to-high-density lipoprotein cholesterol ratio, systolic blood pressure, waist circumference, and smoking (beta = 0.143, P < .05). No differences were observed in average intimamedia thickness measurements alone. Of the nontraditional risk factors, only plasma homocysteine was higher in FDRs then in controls (9.6 mg/L, IQR 8.0-11.1 versus 7.5 mg/L, IQR 6.4-8.7, P < .001), after adjusting for all other confounding variables.

CONCLUSION

First-degree relatives of patients with angiographically confirmed CHD have higher burden of subclinical atherosclerosis even when considered in the context of traditional risk factors. Noninvasive assessment of carotid artery plaques and intimamedia thickness and plasma homocysteine measurements may be useful in such patients.

Identifying genes for coronary artery disease: An idea whose time has come

BACKGROUND

Coronary artery disease (CAD) remains the number one killer in the western world. Genetics accounts for greater than 50% of the risk for CAD. Genetic screening and early prevention in individuals identified as being at increased risk could dramatically reduce the prevalence of CAD, thus necessitating the identification of genes predisposing to CAD. Studies of genes identified by the candidate gene approach have not been replicated due, in part, to inadequate sample size. Genome-wide scan association studies have been limited by the use of thousands of markers rather than the hundreds of thousands required, and by the use of hundreds of individuals rather than the thousands required. Replication of positive findings in an independent population is essential. To detect a minor allele frequency of 5% or greater with an odds ratio for risk of 1.3 or greater and 90% power, an estimated 14,000 (9000 affected and 5000 control) subjects are required.

METHODS

The Affymetrix GeneChip Human Mapping 500K Array Set (Affymetrix Inc, USA) provides a marker every 6000 base pairs as required, and is being used to genotype 1000 cases of premature CAD and 1000 normal subjects, followed by replication in 8000 affected individuals and 4000 control subjects. The phenotype is confirmed or excluded by coronary arteriograms by catheterization or multislice computed tomography.

RESULTS

Since 2005, more than 800 million genotypes have been performed and analyses performed on 500 control subjects and 500 affected individuals. Several thousand significant single nucleotide polymorphisms and 130 clusters associated with CAD have been identified.

CONCLUSIONS

This is the first genome-wide scan using the 500,000 marker set in a case-control association study for CAD genes. Several genes associated with CAD appear promising.

Cholesteryl ester transfer protein B1B1 genotype is associated with a parental history of cardiovascular diseases in Taiwanese people

OBJECTIVE

To investigate the association between family history of cardiovascular disease (CVD) and cholesteryl ester transfer protein (CETP) TaqIB polymorphism in Taiwanese subjects.

SUBJECTS AND METHODS

In this cross-sectional study, 240 subjects (115 men and 125 women) were divided into two groups based on whether or not they had a parental history of CVD. Polymerase chain reaction/restriction fragment length polymorphism was used to analyze the genotype of the subjects for the TaqIB polymorphism of CETP in intron 1.

RESULTS

The frequency of the B1B1 genotype was significantly higher in Taiwanese subjects with a family history of CVD than in those without it (31.2 vs. 18.8%, odds ratio = 1.97, 95% confidence interval = 1.084-3.579, p = 0.035). Siblings with the B1B1 genotype had lower levels of serum high-density lipoprotein cholesterol (HDL-C) than siblings with either B1B2 (46.7 +/- 11.0 vs. 52.5 +/- 11.1 mg/dl, p = 0.034) or B2B2 genotypes (46.7 +/- 11.0 vs. 55.2 +/- 9.6 mg/dl, p = 0.01).

CONCLUSION

CETP TaqIB polymorphism is associated with plasma HDL-C levels. The CETP B1B1 genotype may influence the susceptibility to CVD in Taiwan.

Familial premature coronary artery disease mortality and obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) is linked to both coronary artery disease (CAD) and sudden death, but any causal role remains unclear. A family history of premature CAD and related mortality is an independent risk factor for the development of CAD. We hypothesized that OSA is associated with a family history of premature mortality from ischemic heart disease.

METHODS

We prospectively studied 588 subjects who underwent polysomnography from May 2000 to June 2004. Demographics, comorbidities, family history of cardiovascular disease, and the ages and causes of death for 10 strata of family members were recorded for all subjects. We excluded those subjects with known causes of premature cardiac death, such as hypertrophic cardiomyopathy and long-QT syndrome. OSA was defined by American Academy of Sleep Medicine criteria (ie, apnea-hypopnea index >or= 5). Premature CAD mortality was defined as death due to ischemic heart disease or sudden cardiac death before 55 years of age (men) or 65 years of age (women).

RESULTS

Polysomnography confirmed OSA in 316 subjects and excluded it in 202 subjects. The unadjusted odds ratio (OR) for OSA and a family history of premature CAD mortality was 2.11 (95% confidence interval [CI], 1.10 to 4.31; p = 0.031). After adjusting for each subject's sex, body mass index, and history of CAD, there was a significant and independent association between OSA and family history of premature CAD mortality (OR, 2.13; 95% CI, 1.04 to 4.66; p = 0.046).

CONCLUSIONS

Regardless of their own CAD status, people with OSA are more likely than those without OSA to have a family history of premature CAD mortality.

Personalized genomic medicine: a future prerequisite for the prevention of coronary artery disease

Within the next 10-15 years, medicine will be personalized in large part on the basis of the individual's genomic variants. Coronary artery disease remains the number one cause of morbidity and mortality in the Western world and is predicted to become the number one cause worldwide by 2010. It has been stated that treating the risk factors of coronary artery disease has made it a preventable disease that should be eliminated in the 21st century. It is postulated that about 50% of susceptibility to coronary artery disease is genetic, involving known and occult risk factors. Thus, comprehensive prevention will require identification of genetic susceptibility. The recent technology of a chip with 500,000 DNA markers makes genome-wide scanning to identify the genes contributing to coronary artery disease possible. Multislice CT will provide the high-throughput coronary arteriograms required for this research and for prevention in asymptomatic individuals with a family history of heart disease.

Identification of excess clustering of coronary heart diseases among extended pedigrees in a genealogical population database

BACKGROUND

First-degree family history of early coronary artery disease (CAD) and myocardial infarction (MI) is prognostic among disease-free individuals but may be unreliable. This study evaluated deaths caused by CAD, MI, hypertensive heart disease (HtnHD), and congestive heart failure (CHF) among close and distant relatives.

METHODS

The Utah Population Database contains >2.2 million individual records with genealogy data and 250,000 linked death certificates. Deaths caused by CAD (n = 28,469), MI (n = 26,468), HtnHD (n = 3933), and CHF (n = 11,784) were studied. Familial relative risks (FRRs) were assessed for first- and second-degree relatives. Familiality was also evaluated using the Genealogical Index of Familiality (GIF), which considers close and distant genetic relationships in the Utah Population Database.

RESULTS

Familial relative risks in first-degree (FRR = 1.25, P < .0001) and second-degree (FRR = 1.06, P = .0002) relatives were significant for early age at MI death (<65 years old). Genealogical Index of Familiality analysis demonstrated excess relatedness for deaths caused by MI (case GIF 2.93, mean control GIF 2.73, P < .001) and CHF (2.92 vs 2.66, P < .001). For early age at death, GIFs were significant for MI (3.06 vs 2.54, P < .001), HtnHD (3.22 vs 2.44, P = .003), and CHF (2.64 vs 2.23, P = .003).

CONCLUSIONS

Deaths caused by MI and CHF demonstrate a heritable component in close and distant relatives. For MI, CHF, and HtnHD, for which findings were more pronounced in early age at death, gene discovery may be most effective among early-onset clusters. Excess relatedness was not found for CAD death--perhaps because of heterogeneity within the phenotype--suggesting that this may be a suboptimal phenotype for genetic study.

Genetic Variations in the Tissue Factor Gene Are Associated With Clinical Outcome in Acute Coronary Syndrome and Expression Levels in Human Monocytes

OBJECTIVE

Tissue factor (TF) has, among other factors, a prominent role in acute coronary syndrome (ACS). Our goal was to investigate whether single nucleotide polymorphisms (SNP) in the TF gene (F3) are associated with plasma TF, risk, and outcome in patients with ACS. Moreover, we wanted to investigate the impact of associated TF SNPs on mRNA production in human monocytes.

METHODS AND RESULTS

In 725 patients with ACS [Fragmin and Fast Revascularization during Instability in Coronary Artery Disease II (FRISC-II) study] and 376 controls, 13 SNPs were genotyped and plasma TF measured. Thereafter, the 5466 A>G and the -1812 C>T were genotyped among all of the FRISC-II participants (n=3143) and assessed concerning clinical outcome. Associated SNPs were genotyped in 92 healthy blood donors for comparison of TF activity and TF mRNA expression. None of the SNPs were associated with patient/control status. The 5466 A>G SNP was associated with cardiovascular death (odds ratio, 1.8; P=0.025). The CG haplotype by -1812 C>T and 5466 A>G was associated with a 3-fold increased risk of death (P<0.001). TF mRNA and basal TF activity was significantly lower among 5466 AG carriers, whereas the increase in monocyte TF activity on lipopolysaccharide stimulation was significantly stronger (P=0.04).

CONCLUSIONS

The 5466 AG genotype is a novel predictor of cardiovascular death in ACS and may act through a high TF response.

Clinical application of genetic risk assessment strategies for coronary artery disease: genotypes, phenotypes, and family history

Individuals with genetic predisposition to atherosclerosis have an increased risk for developing coronary artery disease (CAD), especially at young ages. They may derive the greatest benefit from traditional preventive strategies and strategies targeting novel,emerging risk factors. Because CAD is a complex, multifactorial disorder, global risk assessment has been recognized as an effective approach in preventing CAD and its manifestations. The systematic collection and interpretation of family history information is currently the most appropriate screening approach to identify individuals with genetic susceptibility to CAD. Much of the familial aggregation of CAD might be explained by familial aggregation of established risk factors and emerging CAD risk factors. Tests to assess genetic risk for CAD are primarily biochemical analyses that measure the different pathways involved in development and progression of disease. Some of these can guide and explain responses to treatment.

Plasma fibrinogen levels are associated with a strong family history of myocardial infarction

Family history of myocardial infarction (MI) is a known risk factor for coronary artery disease (CAD). The aim of the present study was to investigate whether there is a specific risk factor profile for CAD in individuals with a strong family history of MI occurring at any age. The Study of Health in Pomerania is a cross-sectional, population-based study in the north-east of Germany. A random sample was drawn from the population aged 20-79 years. From 3793 subjects with siblings, 34 (0.9%) reported a history of MI in at least one parent and one sibling. We matched these cases with 136 controls (1 : 4 matching for age, sex and presence of sibling). We then compared cases and controls with respect to known risk factors for MI. Subjects with a dual parental and sibling history of MI had higher plasma fibrinogen levels (3.5 versus 3.0 g/l, respectively), and also more often angina pectoris than the matched controls (P < 0.05). Multivariable analysis revealed an independent association between dual parental and sibling history of MI and plasma fibrinogen levels. We conclude that plasma fibrinogen levels may indicate an inheritable risk for CAD in subjects with a strong family history of MI.

Family burden of cardiovascular mortality: risk implications for offspring in a national register linkage study based upon the Malmö Preventive Project

OBJECTIVE

To investigate the adjusted relative risk of cardiovascular disease (CVD) events in offspring of parents with cardiovascular mortality before 75 years.

SETTING

The city of Malmö, Sweden.

DESIGN

A follow-up study based on register linkage analyses.

SUBJECTS AND METHODS

In the Malmö Preventive Project (MPP), a total of 22,444 men and 10,902 women attended the screening programme between 1974 and 1992. At the screening conventional risk factors for CVD were measured (blood pressure, lipids, glucose, smoking and social class).

MAIN OUTCOME MEASURES

Parental CVD mortality was determined via register linkage analysis between the Multiple-Generation Register and the National Mortality Register (NMR). CVD events (morbidity and mortality) in offspring were collected from national registers. The relative risk for CVD events in offspring, in relation to parental CVD mortality, was adjusted for age and risk factors at screening.

RESULTS

The age-adjusted relative risk (RR; 95%CI) for a son to experience a CVD event was increased in relation to a maternal positive family history of CVD mortality before 75 years when compared with no maternal history, RR 1.74 (1.43-2.11). This RR decreased to 1.51 (1.23-1.84; P < 0.001) after full adjustment for risk factors. The corresponding fully adjusted RRs for father-son heritage was RR 1.22 (1.02-1.47; P < 0.05), mother-daughter RR 0.87 (0.54-1.41), and father-daughter RR 1.20 (0.83-1.73).

CONCLUSION

The existence of maternal CVD mortality before the age of 75 years implies a substantial risk increase for CVD morbidity and mortality in sons that cannot be explained by social background, lifestyle, or conventional cardiovascular risk factors in the adult offspring.

C-reactive protein levels and arterial abnormalities in the offspring of patients with premature myocardial infarction

AIMS

To determine whether high C-reactive protein (CRP) levels and increased intima-media thickness of the common carotid arteries are coexistent in adolescents and young adults with a family history (FH) of premature myocardial infarction (MI).

METHODS

50 healthy young subjects whose parents had had premature MI and 50 control matched subjects were enrolled in the study. CRP levels and the intima-media thickness of the distal common carotid arteries were evaluated in all subjects.

RESULTS

As compared with the control subjects, the offspring of patients with premature MI had a higher CRP concentration (mean +/- SD 8.8 +/- 2.6 versus 3.9 +/- 0.6 mg/l, p < 0.02) and greater intima-media thickness of the common carotid arteries (values for combined sides, mean +/- SD 0.48 +/- 0.02 versus 0.43 +/- 0.02 mm, p < 0.03).

CONCLUSION

High serum levels of CRP and arterial structural changes are coexistent at an early age in subjects with an FH of premature MI.

Genetic evaluation for coronary artery disease

There is substantial evidence that genetic factors contribute to coronary artery disease (CAD). Currently, family history collection and interpretation is the best method for identifying individuals with genetic susceptibility to CAD. Family history reflects not only genetic susceptibility, but also interactions between genetic, environmental, cultural, and behavioral factors. Stratification of familial risk into different risk categories (e.g., average, moderate, or high) is possible by considering the number of relatives affected with CAD and their degree of relationship, the ages of CAD onset, the occurrence of associated conditions, and the gender of affected relatives. Familial risk stratification should improve standard CAD risk assessment methods and treatment guidelines (e.g., Framingham CAD risk prediction score and Adult Treatment Panel III guidelines). Individuals with an increased familial risk for CAD should be targeted for aggressive risk factor modification. Individuals with a high familial risk might also benefit from early detection strategies and biochemical and DNA-based testing, which can further refine risk for CAD. In addition, individuals with the highest familial risk might have mendelian disorders associated with a large magnitude of risk for premature CAD. In these cases, referral for genetic evaluation should be considered, including pedigree analysis, risk assessment, genetic counseling and education, discussion of available genetic tests, and recommendations for risk-appropriate screening and preventive interventions. Research is needed to assess the feasibility, clinical validity, clinical utility, and ethical, legal, and social issues of an approach that uses familial risk stratification and genetic evaluation to enhance CAD prevention efforts.

Family-centered approaches to understanding and preventing coronary heart disease

Family history represents the contributions and interactions of unique genomic and ecologic factors that affect the metabolic profile and life course of a family and its members. It is well known that a family history of coronary heart disease (CHD) is a significant predictor of an individual's risk for CHD even after adjusting for an individual's own established risk factors, such as hypertension, smoking, and abnormal lipoprotein levels. The explanation for the observed familial disease aggregation is not well understood except for the general knowledge that genetic and environmental factors predisposing to CHD also aggregate in families. Given the multifactorial nature of an individual's risk, it can be argued that an individual's familial risk of disease may, in fact, be a better indicator of the many complex interactions among predisposing genetic and environmental factors than can be captured by an individual's own risk factors. Issues of how to assess, quantitate, and apply family history information in clinical settings still need to be resolved. Some clinical risk indicators, such as the National Cholesterol Education Program III guidelines, take into account family history, while others, such as the Framingham Risk Score, do not. Moreover, several family-centered intervention studies have demonstrated the particular advantages of focusing on families rather than just individuals. Although there has been tremendous progress in primary prevention of CHD over the last 20 years, substantial advancements may still be achieved by focusing on the family as its own unit of inference and as a specific target for disease prevention.

Family history assessment: strategies for prevention of cardiovascular disease

Family history assessment can be used to combine population-wide health promotion and risk-reduction efforts with a high-risk, targeted approach to help reduce the burden of cardiovascular disease (CVD). Family history is an independent predictor of CVD, and the upper portion of the family history distribution explains a larger fraction of CVD in the population than can be explained by extreme values of other risk factors (e.g., blood pressure and cholesterol). A positive family history of disease captures the underlying complexities of gene-gene and gene-environment interactions by identifying families with combinations of risk factors, both measured and unmeasured, that lead to disease expression. Family history is a useful tool for identifying most prevalent cases of CVD and for population-wide disease-prevention efforts. A positive family history also identifies the relatively small subset of families in the population at highest risk for CVD who may benefit most from targeted screening and intensive intervention.

Maternal and paternal history of myocardial infarction and risk of cardiovascular disease in men and women

BACKGROUND

Few studies have examined the effects of paternal and maternal history of myocardial infarction (MI), including age at MI, on cardiovascular disease (CVD) risk, particularly among women.

METHODS AND RESULTS

We prospectively studied 22 071 men from the Physicians' Health Study and 39 876 women from the Women's Health Study with data on parental history and age at MI. Among men, 2654 CVD cases developed over 13.0 years; among women, 563 CVD cases occurred over 6.2 years. Compared with men with no parental history, only maternal, only paternal, and both maternal and paternal history of MI conferred relative risks (RRs) of CVD of 1.71, 1.40, and 1.85; among women, the respective RRs were 1.46, 1.15, and 2.05. For men, maternal age at MI of <50, 50 to 59, 60 to 69, 70 to 79, and >/=80 years had RRs of 1.00, 1.88, 1.88, 1.67, and 1.17; for women, the RRs for maternal age at MI of <50, 50 to 59, and >/=60 years were 2.57, 1.33, and 1.52. Paternal age at MI of <50, 50 to 59, 60 to 69, 70 to 79, and >/=80 years in men had RRs of 2.19, 1.64, 1.42, 1.16, and 0.92; in women, for paternal age at MI of <50, 50 to 59, and >/=60 years, the RRs were 1.63, 1.33, and 1.13.

CONCLUSIONS

An early history of parental MI (<60 years) conferred a greater risk of CVD than did MI at older ages. However, an increased risk of CVD remained for maternal age at MI of 70 to 79 years in men and >/=60 years in women, which suggests that any maternal history of MI may be important.

Genetic predisposition to coronary artery disease

Understanding the genetic basis of coronary artery disease (CAD) can improve management and prevention. Family and twin studies, animal models and gene association studies support a genetic basis for CAD. Genes contribute to CAD development and progression, and response to risk factor modification and lifestyle choices. Family history is the best indicator of a predisposition to CAD and further refinement is possible with biochemical and DNA testing. Many inherited cardiovascular risk factors can be modified, such as LDL cholesterol, homocysteine and lipoprotein(a). Early detection of CAD might lead to earlier intervention for genetically susceptible individuals. However, data are lacking regarding the efficacy of this approach in preventing clinical events. Despite this lack of evidence, knowledge of genetic CAD susceptibility has value in providing risk information and guiding decision making. Further research that investigates outcomes regarding genetic risk assessment for CAD is necessary.

Epidemiology and factor analysis of obesity, type II diabetes, hypertension, and dyslipidemia (syndrome X) on the Island of Kosrae, Federated States of Micronesia

OBJECTIVES

Obesity, type II diabetes, hypertension, and dyslipidemia are major causes of morbidity and mortality throughout the world. Though these disorders often cluster in individuals and families and are collectively known as syndrome X, the basis for this aggregation is not well understood. To further understand the pathogenesis of syndrome X, a comprehensive epidemiological study was undertaken on the Pacific Island of Kosrae, Federated States of Micronesia (FSM).

METHODS

The entire adult (>20 years of age) population of Kosrae underwent a clinical evaluation that included a questionnaire that noted the participants' sex, family data including listing of biological parents, siblings, and children, smoking status, village of residence, age and health status. The medical evaluation included: anthropometric measures (weight, height, waist, hip), serum chemistries (leptin, fasting blood sugar (FBS), insulin, total cholesterol (TC), triglycerides (TG), and apolipoproteins B and A-I (apo B and apo A-I) and blood pressure (BP) measurements.

RESULTS

Obesity (BMI >/=35) was found in 24%, diabetes (FBS >/=126 or 2-hour oral glucose tolerance test >/=200) in 12%, hypertension (SBP >/=140 or DBP >/=90) in 17%, and dyslipidemia (TC >/=240 or TG >/=200 or apo B >/=120 or apo A-I </=88) in 20% of the population. Significant covariate effects after multivariate analysis were as follows: sex affected the frequency of all four disorders, parity affected the frequency of dyslipidemia, smoking affected the frequency of obesity and diabetes, village of residence affected the frequency of obesity, hypertension, and dyslipidemia, and age affected the frequency of all four disorders. Factor analysis identified four independent factors that explained 73% of the total variance of the entire data set: factor 1 (weight, waist, leptin, insulin, and TG), factor 2 (TC, TG, apo B, apo A-I, and insulin), factor 3 (systolic and diastolic BP, FBS, waist and weight), and factor 4 (apo A-I, TG, leptin, and weight).

CONCLUSIONS

This population-based study on the Island of Kosrae suggests that syndrome X is a composite of 4 independent factors: obesity with diabetes and hypertriglyceridemia, combined hyperlipidemia with diabetes, hypertension with obesity and diabetes, and increased HDL-low TG with thinness and high leptin. Further studies to identify the genetic components of these factors as well as the individual traits are under way.

Usefulness of cardiovascular family history data for population-based preventive medicine and medical research (the Health Family Tree Study and the NHLBI Family Heart Study)

Detailed medical family history data have been proposed to be effective in identifying high-risk families for targeted intervention. With use of a validated and standardized quantitative family risk score (FRS), the degree of familial aggregation of coronary heart disease (CHD), stroke, hypertension, and diabetes was obtained from 122,155 Utah families and 6,578 Texas families in the large, population-based Health Family Tree Study, and 1,442 families in the NHLBI Family Heart Study in Massachusetts, Minnesota, North Carolina, and Utah. Utah families with a positive family history of CHD (FRS > or =0.5) represented only 14% of the general population but accounted for 72% of persons with early CHD (men before age 55 years, women before age 65 years) and 48% of CHD at all ages. For strokes, 11% of families with FRS > or =0.5 accounted for 86% of early strokes (<75 years) and 68% of all strokes. Analyses of >5,000 families sampled each year in Utah for 14 years demonstrated a gradual decrease in the frequency of a strong positive family history of CHD (-26%/decade) and stroke (-15%/decade) that paralleled a decrease in incidence rates (r = 0.86, p <0.001 for CHD; r = 0.66, p <0.01 for stroke). Because of the collaboration of schools, health departments, and medical schools, the Health Family Tree Study proved to be a highly cost-efficient method for identifying 17,064 CHD-prone families and 13,106 stroke-prone families (at a cost of about $27 per high-risk family) in whom well-established preventive measures can be encouraged. We conclude that most early cardiovascular events in a population occur in families with a positive family history of cardiovascular disease. Family history collection is a validated and relatively inexpensive tool for family-based preventive medicine and medical research.

The effect of amlodipine on endothelial function in young adults with a strong family history of premature coronary artery disease: a randomised double blind study

Endothelial dysfunction, an early event in atherogenesis, has been demonstrated in young asymptomatic subjects with a strong family history of premature coronary artery disease (CAD). In these subjects, preventive measures involving risk factor modification are not appropriate, and strategies employing novel antiatherogenic agents, such as the dihydropyridine calcium channel blocker, amlodipine, may be useful. Ninety-one subjects (mean age, 28.6 years; range, 18-40) with a strong family history of premature CAD and no other identified vascular risk factors were randomised to either 5 mg amlodipine (49 subjects) or placebo (42 subjects). Brachial artery flow mediated dilatation (FMD) (endothelium-dependent response) and response to glyceryltrinitrate (GTN) (direct smooth muscle dilator) were assessed non-invasively at baseline, and after 12 and 24 weeks using high-resolution vascular ultrasound. In those treated with amlodipine, mean FMD increased from 2.32+/-2.23% at baseline to 3.52+/-3.1% at 24 weeks (P<0.005). However, FMD also increased in the placebo group from 1.64+/-2.12 to 3.37+/-2.68% (P<0.002), and the difference between the FMD response in the amlodipine and placebo groups was not significant. Dilatation to GTN did not change in either group. Therefore, impaired endothelial function improved in family history subjects taking both amlodipine and placebo, but there is no difference between the groups.

[Unstable angina in the elderly: clinical, profile, management and mortality at three months. The PEPA Registry Data]

INTRODUCTION AND OBJECTIVES

Few reports in the literature have studied the characteristics and management of unstable angina in the elderly in Spain. The aim of this study was to analyze the clinical characteristics and the use of diagnostic and therapeutic resources in patients > or = 70 years of age.

PATIENTS AND METHODS

A total of 1,551 patients > or = 70 years of age were included out of 4,115 included in the PEPA registry with a follow up of 90 days. These patients were compared with 2,564 < 70 years.

RESULTS

In comparison, the elderly (76 +/- 5 years) versus the younger group (58 +/- 8.5 years) included a higher proportion of women (43 vs 27%), diabetics (30 vs 23%)and hypertensive patients (60 vs 49%) with a lower proportion (p < 0.001) of hypercholesterolemia (33 vs 43%), smoking (40 vs 60%) or family history (9 vs 17%). A previous history of angina (49 vs 35%) or infarction (38 vs31%) and comorbidity was found to be significantly more frequent in the elderly, with a worse previous functional class (NYHA > 2 out of 34 vs 15%). The elderly were treated with fewer invasive procedures (25 vs 44%) or catheterization (26 vs 36%) and they were more frequently controlled with medical treatment (86 vs 83%) although with a lower use of beta blockers (45 vs 53%). The mortality at 3 months was greater in the elderly (7.4 vs 3.0%;p < 0.005) with age being an independent predictor of bad prognosis. Cox multivariate analysis showed the age, ST segment depression, diabetes and heart failure on admission to be predictors of bad prognosis in the elderly.

CONCLUSIONS

A different pattern is observed in cardiovascular risk factors with a more unfavorable clinical profile in elderly patients with unstable angina. The management of these patients is less aggressive and the mortality is greater. Diabetes, heart failure and ST segment depression on admission are independent predictors of bad prognosis in elderly patients.

Risks of coronary heart disease in women: current understanding and evolving concepts

The population of older individuals in the United States is growing rapidly. Because women generally live longer than men and make up the majority of this aging population, the elucidation of health issues related to older women is important. Cardiovascular disease is the leading cause of death and disability for women and claims the lives of more women than the next 14 causes combined. The majority of these deaths are due to atherosclerotic coronary heart disease, with nearly 250,000 women dying of myocardial infarction each year. There is evidence that women with suspected or established cardiovascular disease have not benefited fully from recent advances in the detection and management of coronary heart disease. Regardless of the mechanism and extent of the effect that sex differences have on approaches to cardiovascular disease, women appear to benefit from proven efficacious therapies, and the longer-term outcomes associated with these treatments are positive. The data regarding women and coronary heart disease are rapidly evolving and sometimes conflicting. The intent of this article is to summarize the most current understanding of coronary heart disease risks in women, highlighting the impact of prevention, and to discuss the latest novel findings that may become important in our armamentarium for prevention of coronary heart disease.

Family history of coronary heart disease and pre-clinical carotid artery atherosclerosis in African-Americans and whites: the ARIC study: Atherosclerosis Risk in Communities

The association between family history of coronary heart disease (CHD) and morbidity and mortality due to atherosclerotic sequelae, although well documented in population-based samples of whites, has been little studied in African Americans. Less is known about the relationship between a family history of CHD and pre-clinical atherosclerosis. We report the relation between family history of CHD, summarized in a family risk score (FRS), and asymptomatic atherosclerosis at the extracranial carotid arteries, measured by B-mode ultrasound. The FRS was assessed in relatives of 3,034 African Americans and 9,048 white probands aged 45 to 64 years, in the four community-based cohorts of the ARIC Study. The analyses were restricted to individuals free of clinically manifest CHD. The distribution of CHD FRS by ethnic-gender groups was right skewed, with slightly higher mean values for white than African-American males, and for African-American than white females. In a series of multivariate linear regression models with mean carotid artery intima-media wall thickness (IMT) as the dependent variable, FRS was associated positively with IMT in white and African-American women and white men. In a multiple regression model, approximately one-half of the quantitative statistical relationship of the CHD FRS with IMT in whites was statistically explained by the major risk factors considered as intervening, explanatory variables in this analysis. This association in African-American women was fully explained by the major risk factors. The FRS was not, however, associated with atherosclerosis or major risk factors in African-American males, in the ARIC Study.

Family risk score of coronary heart disease (CHD) as a predictor of CHD: the Atherosclerosis Risk in Communities (ARIC) study and the NHLBI family heart study

Family history of coronary heart disease (CHD) has been found to be a risk factor for CHD in numerous studies. Few studies have addressed whether a quantitative measure of family history of CHD (family risk score, FRS) predicts CHD in African Americans. This study assessed the association between FRS and incident CHD of participants, and the variation of the association by gender and race. Participants in the study were a biracial population-based cohort with 3,958 African Americans and 10,580 Whites aged 45-64 years old in the ARIC baseline survey (1987-1989). They were randomly selected from four U. S. communities. During follow-up (1987-1993), 352 participants experienced the onset of CHD. Incidence density of CHD (per 1,000 person-years) was 7.8 and 3.6 among African-American men (AAM) and women (AAW), and 7.2 and 2.2 among White men (WM) and women (WW). The hazard rate ratio (HRR) of CHD associated with one standard deviation increase of FRS was 1.52 in AAW, 1.46 in AAM, 1.41 in WW, and 1.68 in WM. The HRRs decreased 4.6% in AAW, 1.4% in WW, 5.7% in AAM, and 3.0% in WM, but increased 2.1% in AAM after adjustment for selected covariates. FRS predicts incident CHD in African Americans and Whites, men and women. The relation of FRS to incident CHD can be only partially explained by the selected risk factors in the biological causal pathways: IMT, T-G, LDL, HDL, Lp(a), fibrinogen and hypertension. No significant difference by race has been found in this study.

C-reactive protein in offspring is associated with the occurrence of myocardial infarction in first-degree relatives

The relevance of elevated levels of C-reactive protein (CRP) in cardiovascular disease is gaining increasing recognition. A family history of coronary artery disease is a major determinant of coronary artery disease in the offspring. In a cohort of 1048 individuals without clinical evidence of atherosclerosis, we investigated the relationships between CRP levels and a family history of myocardial infarction. We measured CRP, fibrinogen, plasminogen activator inhibitor-1, total cholesterol, triglycerides, and some genetic polymorphisms: plasminogen activator inhibitor-1 (4G/5G), fibrinogen (Bbeta-chain G-->A(-455)), and angiotensin-converting enzyme insertion/deletion (I/D). Clinical data were collected by a World Health Organization-modified questionnaire for cardiovascular disease. When compared with subjects without first-degree relatives who had suffered a myocardial infarction (n=867), subjects with such first-degree relatives (n=181) were older (P=0.001), more often hypertensive (P<0. 001), and homozygous for the 4G allele (4G/4G) of the plasminogen activator inhibitor-1 gene (P=0.003). In addition, they had a higher body mass index (P=0.036), raised plasma fibrinogen (P<0.007) and total cholesterol (P<0.001) concentrations, and CRP levels >0.33 mg/L (P=0.005). In a multiple logistic regression analysis, age (odds ratio [OR] 1.03, 95% confidence interval [95% CI] 1.01 to 1. 05), total cholesterol (OR 1.35, 95% CI 1.11 to 1.65), plasminogen activator inhibitor-1 4G/4G (OR 1.72, 95% CI 1.20 to 2.45), and CRP levels >0.33 mg/L (OR 1.75, 95% CI 1.05 to 2.91) were all independently associated with a positive family history of myocardial infarction. We therefore conclude that raised levels of CRP independently identify the offspring of patients with a myocardial infarction.

Higher prevalence of GPIIIa PlA2 polymorphism in siblings of patients with premature coronary heart disease

BACKGROUND

The Pl(A2) polymorphism of GPIIIa has been associated with unstable coronary syndromes in some studies, but the association has remained debated. None of the previous studies have focused on families at high risk. Risk factors tend to cluster within kindreds with high prevalence of premature coronary heart disease (CHD). Therefore, a heightened prevalence of the Pl(A2) polymorphism among siblings of patients with CHD would support the hypothesis that Pl(A2) is linked, directly or indirectly, to CHD.

OBJECTIVES

To measure the prevalence of the Pl(A2) polymorphism among siblings of patients with CHD before the age of 60 years and to seek an association between the Pl(A2) polymorphism and established atherosclerotic and thrombogenic risk factors.

METHODS

From January 1994 to April 1996, we genotyped 116 asymptomatic siblings (60 Caucasians, 56 Afro-Caribbeans) of patients with CHD manifestations before the age of 60 years for the Pl(A) polymorphism (also called HPA-1). A control cohort was used for comparison, consisting of individuals that were matched for race and geographic area but were free of CHD (n = 268, 168 Caucasians and 100 Afro-Caribbeans). In addition, we have characterized the sibling cohort for other atherogenic and thrombogenic risk factors.

RESULTS

The prevalence of Pl(A2)-positive individuals (Pl(A2)[+], Pl(A1/A2) heterozygotes plus Pl(A2/A2) homozygotes) in the sibling cohort was high: 41.4%. When analyzed separately, the prevalence of Pl(A2)(+) siblings was 53.3% among Caucasians and 28.6% among Afro-Caribbeans. There was no association between Pl(A2) and other established atherogenic or thrombogenic risk factors. Interestingly, the clustering of other risk factors was lesser among Pl(A2)(+) siblings than their Pl(A1) counterparts.

CONCLUSIONS

This study supports the hypothesis that the prevalence of Pl(A2)(+) individuals is high in kindreds with premature CHD. Hence, like the established risk factors that tend to cluster in families with premature CHD and contribute strongly to the accelerated atherosclerotic process affecting these individuals, the Pl(A2) polymorphism of GPIIIa may represent an inherited risk that promotes the thromboembolic complications of CHD. That these asymptomatic Pl(A2)(+) siblings had overall less established risk factors than their Pl(A1) counterparts might represent an explanation for why they remained asymptomatic despite their Pl(A2) positivity.

Familial predisposition and susceptibility to the effect of other risk factors for myocardial infarction

STUDY OBJECTIVES

To assess if familial predisposition to myocardial infarction (MI) is an indicator of increased susceptibility to the effect of other established risk factors. The study assessed whether a family history of MI modifies the effect of arterial blood pressure, plasma cholesterol, high and low density lipoprotein cholesterol, % triglycerides, diabetes mellitus, body mass index, height, smoking habits, alcohol intake, physical activity level, and educational level on the incidence of MI.

DESIGN

Prospective population based cohort study of cardiovascular risk and risk factors with follow up of MI by record linkage with the Cause of Death Register and The National Hospital Discharge Register until 1994.

SETTING

The Copenhagen Centre for Prospective Population Studies, where data from three Danish studies are integrated.

PARTICIPANTS

Subjects were 24,664 people aged 20-93, examined between 1976 and 1987.

MAIN RESULTS

A total of 1763 new cases of MI occurred during 293,559 person years of observation. All risk factors, including family history of MI reported by 4012 subjects, were, as expected, associated with incidence of MI. With a few inconsistent exceptions we found no significant interactions between family history of MI and cardiovascular risk factors in their effect on MI.

CONCLUSIONS

The familial predisposition to MI does not consistently modify the effect of other risk factors on the risk of MI. However, subjects with a family history of MI may still be regarded as an appropriate target group for screening for cardiovascular risk and intervention against other risk factors.

Bcl I polymorphism in the fibrinogen beta-chain gene is associated with the risk of familial myocardial infarction by increasing plasma fibrinogen levels. A case-control study in a sample of GISSI-2 patients

The aim of this study was to investigate the association of the Bcl I beta-chain fibrinogen polymorphism with the risk of acute myocardial infarction (AMI) and its relationship with fibrinogen levels in the Italian population. We studied 102 AMI patients, selected within the framework of the GISSI-2 trial, who had a familial history of arterial thrombosis (at least one first-degree relative suffering from AMI or stroke before 65 years) and 173 control subjects (with neither AMI nor personal or familial history of arterial thrombosis). All subjects were Italian. Patients showed fibrinogen levels higher than control subjects. There was a highly significant difference in allele frequency in cases versus control subjects, the B2 allele frequencies being respectively 0.28 versus 0.17 (P = .002). In multivariate analysis, adjusted for sex, age, smoking habits, and history of hyperlipidemia, hypertension, or diabetes, the (B1B2 + B2B2) genotype was associated with a higher risk of AMI (odds ratio 2.4, 95% confidence interval, 1.2 to 4.6). The Bcl I genotype was also associated with fibrinogen levels, independently of gender and smoking habits, the (B1B2 + B2B2) subjects showing the highest levels in both cases and control subjects. The difference in fibrinogen levels between cases and control subjects was significantly influenced by the genotype (significant interaction, P = .042). The B2 allele of the Bcl I polymorphism in the beta-chain of the fibrinogen gene is a new factor associated with the risk of familial AMI through its association with fibrinogen levels. These data provide evidence for a causal role of fibrinogen in familial AMI.

Endothelium-dependent dilatation is impaired in young healthy subjects with a family history of premature coronary disease

BACKGROUND

A family history of premature coronary artery disease (CAD) in a first-degree relative is an independent risk factor for coronary disease. Both genetic and environmental influences are likely to be responsible and may interact, but their relative importance is unclear.

METHODS AND RESULTS

We studied endothelial function in 50 first-degree relatives (31 men, 19 women; mean age, 25+/-8 years) of patients (men < or = 45 years, women < or = 55 years) with proven CAD. All subjects were well, lifelong nonsmokers, not diabetic, and not hypertensive and took no medications. Using high-resolution external vascular ultrasound, we measured brachial artery diameter at rest and in response to reactive hyperemia (with increased flow causing an endothelium-dependent vasodilatation) and to sublingual glyceryltrinitrate (GTN, an endothelium-independent dilator). Vascular responses were compared with those of 50 healthy control subjects matched for age and sex. Flow-mediated dilatation (FMD) was impaired in the family history group (4.9+/-4.6% versus 8.3+/-3.5% in control subjects, P<.005). In contrast, GTN caused dilatation in all subjects (family history, 17.1+/-8.8%; control subjects, 19.0+/-6.3%; P=NS), suggesting that reduced FMD was due to endothelial dysfunction. When the family history subjects were subdivided, those found to have a serum cholesterol > 4.2 mmol/L (group A, n=10) had mildly impaired FMD compared with control subjects (5.5+/-5.1% versus 8.3+/-3.5%). In others whose affected relative had coronary risk factors (group B, n=24), FMD was also only slightly reduced (6.2+/-4.8% versus 8.3+/-3.5%). In contrast, subjects with no risk factors and whose affected relative had a normal cardiovascular risk factor profile (group C, n=16) had markedly impaired FMD (2.9+/-3.7% versus 8.3+/-3.5%). Although ANOVA of the three family history subgroups did not reach statistical significance (F=2.55, P=.09), pairwise analysis showed that FMD in group C was significantly impaired compared with group B (P=.026).

CONCLUSIONS

Healthy young adults with a family history of premature coronary disease may have impaired endothelium-dependent dilatation, even in the absence of other cardiovascular risk factors. Those subjects, who were free of risk factors and whose affected first-degree relative was free of risk factors, had the most impaired endothelial function, suggesting a genetic influence on early arterial physiology that may be relevant to later clinical disease.

Low-density lipoprotein particle size is not a discriminating marker for atherogenic risk in male offspring of parents with early coronary artery disease

The aim of this study was to assess the importance of low-density lipoprotein (LDL) particle size as a marker of atherogenic risk in male offspring of a parent with early coronary artery disease (CAD) before the age of 60 years. CAD-positive (CAD+) offspring were recruited into two groups based on age, 15 to 30 years (n = 20) and 31 to 45 years (n = 41), and matched to CAD-negative (CAD-) offspring by age and body mass index (BMI) (n = 20 and 21 per group). LDL peak particle diameter was assessed by polyacrylamide gradient gel electrophoresis. There was no significant difference in LDL peak particle diameter between CAD+ and CAD- offspring (26.2 +/- 0.1 v 26.2 +/- 0.1 nm, mean +/- SE). There was also no difference between CAD+ offspring and CAD- offspring when comparisons were made within their own age group (26.5 +/- 0.1 nm in younger CAD+ offspring v 26.2 +/- 0.1 nm in younger CAD- offspring, and 26.0 +/- 0.1 nm in older CAD+ offspring v 26.1 +/- 0.2 nm in older CAD- offspring). Peak particle diameter was significantly greater in younger CAD+ offspring than in older CAD+ offspring (26.5 +/- 0.1 v 26.0 +/- 0.1 nm, P < .05). We conclude that small LDL particle size is not a discriminating marker for early atherogenic risk, and that measurement of LDL particle size has limited value in the assessment of coronary risk, at least in the age ranges we studied.

Frequency of family history of acute myocardial infarction in patients with acute myocardial infarction. Argentine FRICAS (Factores de Riesgo Coronario en America del Sur) Investigators

The relation between family history of acute myocardial infarction (AMI) and the risk of AMI was analyzed using data of a case-control study conducted in Argentina between 1992 and 1994. Case patients were 1,060 subjects with AMI admitted to 35 coronary care units, and controls were 1,071 subjects admitted to the same network of hospitals where cases had been identified, for a wide spectrum of acute conditions unrelated to known or likely risk factors for AMI: 31% of cases versus 15% of controls reported > or = 1 first-degree relative with history of AMI. Compared with subjects without family history of AMI, the odds ratio (OR) of AMI, after allowance for age, sex, cholesterolemia, smoking, diabetes, hypertension, body mass index, education, social class, and physical exercise, was 2.18 (95% confidence interval [CI] 1.74 to 2.74) for those with family history of AMI. The OR was 2.04 (95% CI 1.60 to 2.60) for subjects with 1 relative, and 3.18 (95% C 1.86 to 5.44) for those reporting > or = 2 relatives with AMI. In women the OR for any family history of AMI was 2.83, and in men 2.01. The association was of similar magnitude if the mother (OR 1.98), the father (OR 2.13), or a sibling (OR 2.48) had had an AMI. The association with family history was stronger at a younger age because the OR for subjects reporting > or = 2 more relatives with a history of AMI was 4.42 for subjects aged < 55 years, and 3.00 for those aged > or = 55 years. The association between AMI and family history of AMI was consistent across separate strata of education, social class, smoking, and serum cholesterol, but was less strong in subjects with history of diabetes and hypertension. When the interaction of known risk factors with family history of AMI was analyzed, hypercholesterolemia, hypertension, and smoking had approximately multiplicative effects on the relative risk. The OR was 4.50 for subjects with family history and cholesterol > or = 240 ml/dl, 4.52 for those with hypertension, and 5.77 for current smokers with family history of AMI. Thus, this study confirms that a family history of AMI is a strong and independent risk factor for AMI. In this population from Argentina, family history accounted for 14% of all cases of AMI in men and 26% in women.

Cardiovascular risk factor profile in subjects with familial predisposition to myocardial infarction in Denmark

STUDY OBJECTIVES

To identify possible modifiable mediators of familial predisposition to myocardial infarction (MI) by assessing the risk factor profile in individuals without MI in relation to parental occurrence of MI.

DESIGN AND METHODS

Cross sectional survey of the general population. The odds of an adverse cardiovascular risk factor profile in subjects reporting parental occurrence of MI versus subjects not reporting parental occurrence were estimated by logistic regression models.

SETTING

The Copenhagen Centre for Prospective Population Studies, where subjects investigated in three Danish prospective population studies are integrated.

PARTICIPANTS

Subjects were 9306 females and 11,091 males aged 20-75 years with no history of MI. A total of 1370 subjects reported maternal MI and 2583 reported paternal MI.

MAIN RESULTS

Increased systolic and diastolic blood pressure, increased cholesterol level, low ratio between high density lipoprotein (HDL) and total cholesterol (TC), and heavy smoking, were more frequent in subjects with parental occurrence of MI than in controls irrespective of sex and age of the subjects. Maternal MI was more predictive for increased cholesterol and decreased HDL/ TC ratio than paternal MI, and the risk of an increased cholesterol level was higher in subjects aged 20-39 years than in older subjects. No differences in body mass index, triglycerides, and physical inactivity were observed.

CONCLUSIONS

Subjects free of previous MI who reported a parental occurrence of MI had an adverse cardiovascular risk factor profile regarding systolic and diastolic blood pressure, total cholesterol, the ratio between HDL and total cholesterol, and smoking. Thus, these modifiable risk factors may be mediators of the familial predisposition to MI.