Biologic and psychosocial risk factors of sudden death from coronary disease in white women

The Spillover Influence of Partner's Education on Myocardial Infarction Incidence and Survival

BACKGROUND

Education is believed to have positive spillover effects across network connections. Partner's education may be an important resource preventing the incidence of disease and helping patients cope with illness. We examined how partner's education predicted myocardial infarction (MI) incidence and survival net of own education and other socioeconomic resources in Finland.

METHODS

A sample of adults aged 40-69 years at baseline in Finland in 1990 was followed up for MI incidence and mortality during the period 1991-2007 (n = 354,100).

RESULTS

Lower own and spousal education both contributed independently to a higher risk of MI incidence and fatality when mutually adjusted. Having a partner with basic education was particularly strongly associated with long-term fatality in women with a hazard ratio of 1.53 (95% confidence interval, 1.22-1.92) compared with women with tertiary level educated partners. There was some evidence that the incidence risk associated with basic spousal education was weaker in those with own basic education. The highest risks of MI incidence and fatality were consistently found in those without a partner, whereas the most favorable outcomes were in households where both partners had a tertiary level of education.

CONCLUSIONS

Accounting for spousal education demonstrates how health-enhancing resources accumulate to some households. Marriage between people of similar educational levels may therefore contribute to the widening of educational differences in MI incidence and survival.

Ischaemic heart disease, stroke and total mortality in women--results from a prospective population study in Gothenburg, Sweden

The aims of this study were to determine the prognosis for women with different symptoms and signs indicating ischaemic heart disease and to relate entry characteristics to events of ischaemic heart disease and stroke, and to overall mortality during a 12-year follow-up period. A prospective cohort study was started as a cross-sectional investigation in 1968-69 (1462 participants aged 38-60, participation rate 90.1%). The same sample was re-studied in 1980-81 (1154 participants, participation rate 78.9% of those studied in 1968-69). In addition, a clinical series comprising all women of similar age in Gothenburg with myocardial infarction during the years 1968-70 (47 women) was followed up for 12 years. The 12-year overall mortality rate for women with initial myocardial infarction in the clinical series was 45%. The 12-year overall mortality rates for women who at the time of the initial study either were considered to have angina pectoris or showed electrocardiographic changes indicating ischaemic heart disease at rest or at work were 10%, 17% and 10% respectively (expected figures 7%, 12% and 10%). Twenty-three women (1.6%) developed myocardial infarction during the follow-up period (8 fatal, 15 non-fatal). New symptoms of angina pectoris were recorded in 56 women (4.0%), new electrocardiographic changes indicating ischaemic heart disease in 73 women (6.0%), and new signs of stroke in 13 women (0.9%). Altogether 75 women (5.1%) died during the follow-up period. These five end-points were taken into consideration. Women with previously untreated arterial hypertension were offered control visits during the follow-up period and were prescribed antihypertensive drugs when clinically indicated. In this group of women, hypertension was not a predictor for any of the end-points. No other systematic intervention was carried out. Increased abdominal adiposity, increased serum triglycerides and low peak expiratory flow were independent predictors of at least three of the end-points studied: myocardial infarction, stroke and death. Increased abdominal adiposity was also an independent predictor of angina pectoris. Initial diabetes was an independent predictor of both myocardial infarction and of death. Low energy intake predicted myocardial infarction and electrocardiographic changes indicating ischaemic heart disease. High serum gastrin levels predicted myocardial infarction. Low education and high degree of mental disorder were independent predictors of angina pectoris. Physical inactivity at leisure and physical inactivity at work were independent predictors of stroke and of death, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)

Risk factors for coronary heart disease in women

The increased focus on risk factors for CHD in women has greatly improved our understanding of this disease in women. The evidence against cigarette smoking, elevated serum cholesterol, and high blood pressure is strong, and sustained campaigns are underway to prevent and appropriately manage these conditions. The importance of adequate physical activity and weight control is well established, and research continues on other emerging risk factors. The focus of future research will be on clarifying the role of these factors, particularly for women and ethnic minorities.

Update on cardiovascular disease in post-menopausal women

Cardiovascular disease (CVD), and in particular coronary artery heart disease (CAHD), is the leading cause of morbidity and mortality in women. Until recently, most of our knowledge about the pathophysiology of CVD in women - and, subsequently, management guidelines - were based on studies conducted mostly in men. While similar mechanisms operate to induce CVD in women and men, gender-related differences exist in the anatomy and physiology of the myocardium, and sex hormones modify the course of disease in women. Women, more than men, have their initial manifestation of CAHD as angina pectoris; are likely to be referred for diagnostic tests at a more advanced stage of disease, and are less likely than men to have corrective invasive procedures. The overall morbidity and mortality following the initial ischaemic heart event is worse in women, and the case fatality rate is greater in women than in men. Also, the relative impact of impaired vasoreactivity of the coronary artery, increased viscosity of the blood and dysregulation of automaticity and arrhythmia, is greater in women than in men. The most effective means of decreasing the impact of CVD on women's health is by an active approach from childhood to proper principles of healthcare in order to modify the contribution of specific risk factors. The latter include obesity, abnormal plasma lipid profile, hypertension, diabetes mellitus, cigarette smoking, sedentary lifestyle, increased blood viscosity, augmented platelet aggregability, stress and autonomic imbalance. The use of lipid-lowering drugs has not been adequately studied in women but reports from studies conducted mostly in men do predict an advantage also to women. Oestrogen deficiency after spontaneous or medically induced menopause is an important risk factor for CVD and CAHD. Observational and mechanistic data suggest a role for oestrogen replacement after menopause for primary, and possibly secondary, prevention of CVD. However, two recent prospective trials suggest that treatment de novo with hormone replacement of older post-menopausal women after an acute coronary event may not confer cardiovascular protection and may increase the risk of thromboembolic disease. Results of ongoing long-term studies may determine the beneficial role of hormone replacement versus potential risks involved with this treatment.

Cardioprotective benefits of hormone replacement therapy

PURPOSE

To examine the effect of hormone replacement therapy (HRT) on adverse cardiac events in postmenopausal women.

DATA SOURCES

A systematic review of all available scientific literature (513 articles) on the cardioprotective benefits of HRT, including research reports, meta-analyses, and commentaries.

CONCLUSIONS

Epidemiological studies have consistently suggested that HRT administered to postmenopausal women significantly lowers the risks of cardiovascular events. However, the claimed benefits might have been exaggerated. The results of the only large randomized clinical trial did not show similar benefits as those reported from observational studies. Research findings about cardiovascular protection of HRT remain inconclusive.

IMPLICATIONS FOR PRACTICE

While waiting for more definitive data, it is appropriate to consider other options that have been proven safe and effective in the prevention of cardiovascular disease.

Hormone replacement therapy and the risk of myocardial infarction in women with coronary risk factors

To assess the risk of myocardial infarction in users of post-menopausal hormone replacement therapy who are at high risk of coronary disease because of hypertension, diabetes mellitus, or smoking, we used data from a previously published case-control study of women 45-74 years. After adjustment for age, ethnicity, and education, the odds ratio for myocardial infarction in current users of hormone replacement therapy was 0.9 (95% confidence interval (CI) = 0.5-1.6) in women with no major coronary risk factors, 0.8 (95% CI = 0.5-1.8) in women with one risk factor, and 1.1 (95% CI = 0.5-2.2) in women with two risk factors.

Behavioral risk factors of sudden cardiac arrest

OBJECTIVE

The purpose of this study was to investigate the association between sudden cardiac arrest (SCA) and the behavioral factors exhaustion and nonexpression of emotions.

METHODS

Case-control study of 99 victims of SCA and 119 coronary controls, matched for gender and age.

RESULTS

Victims of SCA were more often assessed as exhausted and as closed by their family members than controls. A significant interaction between exhaustion and closeness on the risk of SCA was observed. Those who were exhausted and did not express their emotions had a sevenfold greater risk of SCA.

CONCLUSION

The behavioral factor of exhaustion and nonexpression of emotions may contribute to the identification of persons at elevated risk for SCA.

Reproductive history and cardiovascular disease risk in postmenopausal women: a review of the literature

OBJECTIVES

It is widely believed that oestrogen protects postmenopausal women from cardiovascular disease. It is unknown, however, whether reproductive history, which affects endogenous oestrogen levels during a woman's life, also influences cardiovascular disease risk in postmenopausal women. We present an overview of the studies which investigate the relationship between reproductive history and risk for cardiovascular disease in women.

METHODS

We conducted a Medline search of literature pertaining to age at menarche, age at menopause, parity and gravidity, breast-feeding, and length and regularity of the menstrual cycle in relation to cardiovascular diseases. Data extraction and synthesis were performed by comparing odds ratios and relative risks presented or calculated.

RESULTS

Age at menarche was not found to influence cardiovascular disease risk, while menstrual cycle irregularity was associated with this risk. The studies pertaining to parity presented conflicting results: protection against as well as an increase in the risk of cardiovascular disease were found in parous women. Pregnancy loss appeared to be related to cardiovascular disease risk. Age at menopause proved to be the reproductive factor most clearly related to cardiovascular disease risk.

CONCLUSIONS

Only menstrual cycle irregularity, pregnancy losses, and age at menopause are possibly related to cardiovascular disease risk in postmenopausal women. All reproductive factors need to be studied together in order to assess reproductive history in a proper manner. Research of this kind will be essential if we are to further increase our knowledge regarding the nature of the effects of endogenous oestrogen on cardiovascular disease.

Hormone replacement therapy, heart disease, and other considerations

Multiple observational studies suggest a marked reduction in risk of coronary heart disease (CHD) associated with postmenopausal estrogen use. A new meta-analysis presented here extends these results to estrogen plus progestin regimens. Although the findings from observational studies are strong and consistent, and there are several plausible mechanisms by which estrogen might reduce risk for CHD, most of the known biases would tend to exaggerate estrogen's benefit. Further, estrogen therapy clearly increases risk for endometrial hyperplasia and cancer, venous thromboembolic events and gallbladder disease, and long-term use probably also increases the risk of breast cancer. Therefore, until findings from randomized trials confirm and quantitate the benefit of estrogen therapy for prevention of CHD, we believe it should not be recommended to all postmenopausal women.

Sex hormones and vascular reactivity

It is increasingly recognized that sex steroids have, among many other effects, the ability to cause vasodilation. The vasodilatory effects of estradiol have been the best documented and described. At low concentrations, estradiol has the ability to improve impaired endothelium dependent (nitric oxide mediated) relaxation in estrogen deficient subjects. At high concentrations, estradiol causes vasodilation principally by endothelium independent mechanisms, in a gender independent fashion, which appear to involve a number of pathways such as ATP-dependent K+ channels. Testosterone also has ability, at higher doses, to cause vasodilation of the coronary circulation, in a gender independent fashion. The mechanisms of sex steroid-induced vasodilation are reviewed in this article.

Sex differences in cardiac arrest survivors

BACKGROUND

Important sex differences in the epidemiology of sudden death and in the results of electrophysiological testing in survivors of cardiac arrest have been identified. These differences are currently poorly understood.

METHODS AND RESULTS

Three hundred fifty-five consecutive survivors of out-of-hospital cardiac arrest (84 women and 271 men) referred for electrophysiologically guided therapy were analyzed retrospectively for sex differences in underlying pathology and predictors of outcome. Women were significantly less likely to have underlying coronary artery disease than men (45% versus 80%) and more likely to have other forms of heart disease or structurally normal hearts (P<.0001). The mean left ventricular ejection fraction was higher in women (0.46+/-0.18 versus 0.41+/-0.18, P<.05), and women were more likely to have no inducible arrhythmia at baseline electrophysiological testing (46% versus 27%, P=.002), although when the patients were stratified by coronary artery disease status, these sex differences were no longer present. The independent predictors of outcome differed between men and women. In men, a left ventricular ejection fraction of <0.40 was the most powerful independent predictor of total (relative risk, 2.8; 95% CI, 1.6 to 5.0; P<.0001) and cardiac (relative risk, 6.3; 95% CI, 2.9 to 13.5; P<.0001) mortality. In contrast, the presence of coronary artery disease was the only independent predictor of total (relative risk, 4.5; 95% CI, 1.5 to 13.4; P=.003) and cardiac (relative risk, 4.4; 95% CI, 1.2 to 15.6; P=.012) mortality in women.

CONCLUSIONS

Females survivors of cardiac arrest are less likely to have underlying coronary artery disease. The predictors of total and cardiac mortality differ between male and female survivors. Coronary artery disease status is the most important predictor in women, and impaired left ventricular function is the most important predictor in men.

Sex differences in sickness absence in relation to parental status

The aim of this study was to analyse sex differences in medically certified sickness absence with special regard to parental status and age. All new sick-leave spells exceeding seven days and certified by a physician in a county of Sweden were registered in 1985-1987. The data-base was related to the population at risk by using data from the Swedish Official Population and Housing Census 1985. The analysis concerned the employed population in the age group from 16 to 54 with and without custody of children younger than ten years. In all ages, women with children had more sickness absence than men with children. Corresponding sex differences did not appear for persons without children, except for the oldest age-groups. Men with children had the lowest sickness absence of all groups. Young women with children had the highest. These findings remained the same when pregnancy-related sickness absence was excluded. The common finding of sex differences in sickness absence is here highly interrelated to custody of small children. The results suggest that the often reported positive health effects of multiple roles in women may be counteracted by inequality between the sexes in the responsibility as parents.

Impact of antiseizure medication level on the incidence of sudden unexplained death from epilepsy in patients from an inner city emergency department

Sudden unexplained death from seizures (SUDS) accounts for death in approximately 10% of the epileptic population. SUDS usually occurs in young males with a history of seizure disorders who are in otherwise good health. No definitive anatomical lesions are found at autopsy that explain death. There is however, a correlation between SUDS and subtherapeutic levels of antiseizure medications. The purpose of this study was to retrospectively review and compare drug levels from a seizure patient that presented to an inner city emergency department to those from the medical examiners office. This study was prompted by a wrongful death claim for substandard care in a known seizure disorder patient. The claim alleged that the death was directly attributed to subtherapeutic seizure medication levels. We report the results from 150 seizure patients that presented to the emergency department with a chief complaint of a recent seizure and of 163 patients that were examined post mortem. 58% of the emergency department patients who were taking phenytoin, 79% taking carbamazapine and 82% of the patients taking phenobarbital had subtherapeutic levels. No patient in this population died and only 13% required hospital admission. These levels were comparable to the post mortem population.

Contribution of job strain, job status and marital status to laboratory and ambulatory blood pressure in patients with mild hypertension

The effects of job strain, occupational status, and marital status on blood pressure were evaluated in 99 men and women with mild hypertension. Blood pressure was measured during daily life at home and at work over 15 h of ambulatory blood pressure monitoring. On a separate day, blood pressure was measured in the laboratory during mental stress testing. As expected, during daily life, blood pressure was higher at work than at home. High job strain was associated with elevated systolic blood pressure among women, but not men. However, both men and women with high status occupations had significantly higher blood pressures during daily life and during laboratory mental stress testing. This was especially true for men, in that men with high job status had higher systolic blood pressures than low job status men. Marital status also was an important moderating variable, particularly for women, with married women having higher ambulatory blood pressures than single women. During mental stress testing, married persons had higher systolic blood pressures than unmarried individuals. These data suggest that occupational status and marital status may contribute even more than job strain to variations in blood pressure during daily life and laboratory testing.

Southwestern Internal Medicine Conference: postmenopausal estrogen supplementation: a cardiologist's perspective

Women live nearly one third of their lives after ovarian function has ceased. The implications of menopause for both health and disease as well as the risks and benefits of hormonal replacement therapy are important considerations in the management of postmenopausal women. The author discusses the relation between menopause and coronary heart disease (CHD) risk and evaluates the risks and benefits of hormonal replacement therapy from a cardiologist's perspective. During menopause, there are changes in the lipid profile that favor the development of CHD. In addition, there is convincing evidence that the risk of CHD increases with surgical menopause and that natural menopause also may signal a period of increasing risk. Data from angiographic and prospective studies suggest that a reduction in CHD risk is associated with estrogen use in postmenopausal women and that a large part of the beneficial effect of estrogen on CHD risk is through changes in the lipid profile. The benefit of hormonal replacement therapy for reduced risk of CHD, however, must be viewed in the setting of the overall risks and benefits of hormonal replacement therapy for each individual patient.

Spouse similarity for psychological distress and well-being: a population study

While spouse similarity for psychiatric morbidity has been the object of numerous studies, most of these focused on clinical samples and, consequently, the interpretation of their results is limited by the existence of a selection bias. In this study, conducted on a sample of 845 general population couples, significant spouse similarity was observed for psychological distress and well-being, characterized by a marked symmetry in the relation between spouses' scores. The sex differences observed in many earlier studies would appear essentially to be artefactual. Spouse similarity was also found to be significant in the subpopulation of couples married less than two years, which pointed to assortative mating for psychological distress and well-being. While many studies have found educational dissimilarity and age difference between spouses to be associated with certain health variables, such as high blood pressure and coronary heart disease, these variables do not have a significant influence on individual levels of psychological distress and well-being. Spouse similarity for socio-demographic characteristics does not play a significant role in explaining spouse similarity for mental health. Consequently, assortative mating for psychological distress and well-being would appear to be primarily due to personal preference.

Impact of the menopause on the epidemiology and risk factors of coronary artery heart disease in women

Cardiovascular disease is the leading cause of morbidity and mortality in women, and coronary artery heart disease (CHD) is the largest single component of fatal cardiovascular disease. Gender-related differences are observed in the symptomatology, natural course and outcome, and in the management of the acute coronary event. More women, compared to men, have angina as their first manifestation of CHD, and they are less likely to have serious stenosis. Women undergo less invasive diagnostic procedures, but have an overall prognosis that is worse than that of men. Rates of CHD in women increase after the fifth-sixth decades of life, suggesting that young women have a protective factor that is lost after the fifth decade. Because most women become menopausal during this age range, it is speculated that the protective factor may the female hormone, estrogen. This conclusion is supported by results of epidemiological studies indicating an increased risk of CHD in women with early-onset menopause and a reduced risk in postmenopausal women treated with estrogen replacement therapy. The impact of the menopausal transition on other CHD risk factors is still not fully understood. Reduced estrogen levels resulting from the menopausal transition have been implicated in adverse effects on obesity and fat distribution, plasma lipid profile, and rheological properties of plasma and platelet function. Postmenopausal estrogen deficiency may also aggravate preexisting diabetes mellitus and hypertension, and have an overall negative effect on the reaction to stress. These data suggest that estrogen deficiency can directly and indirectly promote CHD in women. More research is needed to clarify and differentiate menopause-related from aging-related effects on the risk of CHD women.

Ventricular tachycardia and psychiatric depression in patients with coronary artery disease

PURPOSE

The purpose of this study was to examine the relationship between psychiatric depression and ventricular arrhythmias in patients with coronary artery disease (CAD). The hypothesis was that depressed patients with CAD would have a higher prevalence of ventricular tachycardia (VT) than nondepressed patients with CAD.

PATIENTS AND METHODS

One hundred three patients who were found to have significant CAD by elective diagnostic cardiac catheterization were administered a standardized psychiatric interview and underwent 24-hour Holter monitoring.

RESULTS

Twenty-one patients (20%) met the criteria for either major or minor depression. There were no significant differences between depressed and nondepressed patients with CAD in severity of CAD or in ventricular function. Five (23.8%) of the depressed patients and three (3.7%) of the nondepressed patients exhibited episodes of VT during 24 hours of Holter monitoring (p < 0.008). This difference remained significant even after controlling for relevant covariates.

CONCLUSIONS

We conclude that there is a higher prevalence of VT among patients with CAD and depression than among those CAD patients without depression. This may help to explain the increased risk for cardiac mortality in depressed patients with CAD.

Epidemiological overview of oestrogen replacement and cardiovascular disease

In contrast to numerous epidemiological studies of prevention in men, there has been limited research into the prevention of cardiovascular disease in women. Nevertheless, sufficient data have accumulated showing that OeRT does protect against circulatory disease in women, although evidence regarding the true magnitude of that protection remains incomplete. The best estimates of the relationship between OeRT and CVD come from population-based prospective studies which are remarkably consistent: overall they indicate a 40% reduction in CVD with use of OeRT. However, because of the underlying better health of the postmenopausal women who use hormone replacement therapy, this result probably overestimates the benefit of OeRT by an unknown degree. Furthermore, details of OeRT formulation (especially the influence of regimens with an added progestin), dose, duration, and route of administration have not been adequately studied, and the evidence regarding the effect of OeRT on rates of stroke is equivocal and requires clarification. Oestrogen's cardioprotection appears to derive from favourable effects on serum lipoprotein profiles. There may also be a direct effect on the arterial system. Detrimental influences of OeRT on haemostatic function seem unlikely. Definitive information about the actual size of effects of commonly-used regimens of OeRT on cardiovascular disease and intermediate endpoints such as serum lipid concentrations can only be obtained through large-scale randomized controlled trials. Even if the reduction in CVD were modest, the mortality rates of CVD in our society are still so high that widespread use of oestrogen replacement therapy would result in substantial numbers of women's lives being saved.

Work, marital status, and heart disease

Longitudinal data from the U.S. National Health and Nutrition Survey and its follow-up were used to analyze the effects of marriage and work roles and changes in these roles on the incidence of coronary heart conditions in a sample of 3,097 middle-aged women. Education, age, family income, race, and number of children were included as covariates. The data indicated that women who became unmarried, younger women, and better educated women were at relatively low risk, whereas women who left the labor force and women who were homemakers were at relatively high risk for the conditions. Additional analyses were done on employed women. These findings support the "well-worker effect" but cast doubt on the belief that marriage is always beneficial to health.

Extraskeletal effects of estrogen and the prevention of atherosclerosis

A cumulative effect has been calculated by Henderson et al. concerning the estimated changes in mortality with estrogen therapy. Even assuming a twofold increase in the risk of breast cancer, the benefits derived from reduction of osteoporotic fractures and the decreased risk of heart disease, demonstrate a 41% decrease in mortality in women who receive estrogen therapy. Since cardiovascular disease is the major cause of morbidity and mortality in postmenopausal women, and since the beneficial effects of estrogen outweigh the documented and perceived risk of estrogen use, estrogen ought to be considered as prophylactic therapy, particularly in women at risk of heart disease.

Burnout as a risk factor for coronary heart disease

During the preparation of a prospective study of exhaustion as a precursor of myocardial infarction (MI), the authors found that many coronary patients said that they had been burned out at some time in their lives. Therefore, the question, "Have you ever been burned out?" was included in the study. The cohort was formed by 3,877 men, aged 39 to 65, and was followed up on for 4.2 years. Among the men who were free of coronary heart disease (CHD) at screening, 59 subjects experienced a fatal or nonfatal myocardial infarction during follow-up. Those who endorsed the above question when they entered the study were found to be at increased risk for myocardial infarction when the authors controlled for age, blood pressure, smoking, and cholesterol; RR (relative risk) = 2.13; p less than .01. About one third of those who were exhausted before myocardial infarction had been burned out at some time in their lives, chi 2 = 7.09, p less than .01. The data indicate that a state of exhaustion before myocardial infarction is often a reactivation of earlier periods of breakdown in adaptation to stress.

Estrogen replacement therapy and coronary heart disease: a quantitative assessment of the epidemiologic evidence

Considerable epidemiological evidence has accumulated regarding the effect of postmenopausal estrogens on coronary heart disease risk. Five hospital-based case-control studies yielded inconsistent but generally null results; however, these are difficult to interpret due to the problems in selecting appropriate controls. Six population-based case-control studies found decreased relative risks among estrogen users, though only 1 was statistically significant. Three cross-sectional studies of women with or without stenosis on coronary angiography each showed markedly less atherosclerosis among estrogen users. Of 16 prospective studies, 15 found decreased relative risks, in most instances, statistically significant. The Framingham study alone observed an elevated risk, which was not statistically significant when angina was omitted. A reanalysis of the data showed a nonsignificant protective effect among younger women and a nonsignificant increase in risk among older women. Overall, the bulk of the evidence strongly supports a protective effect of estrogens that is unlikely to be explained by confounding factors. This benefit is consistent with the effect of estrogens on lipoprotein subfractions (decreasing low-density lipoprotein levels and elevating high-density lipoprotein levels). A quantitative overview of all studies taken together yielded a relative risk of 0.56 (95% confidence interval 0.50-0.61), and taking only the internally controlled prospective and angiographic studies, the relative risk was 0.50 (95% confidence interval 0.43-0.56).

Mental precursors of myocardial infarction

Both cardiologists and psychiatrists have observed that the onset of myocardial infarction is often preceded by feelings of decreasing energy, general malaise, and minor depression. This paper describes these observations and tries to integrate the findings. It is proposed that the mental state preceding myocardial infarction can be best described as 'vital exhaustion'.

V.A. Cooperative Study of antiplatelet agents in diabetic patients after amputation for gangrene: unobserved, sudden, and unexpected deaths

We report on unobserved, sudden, and unexpected deaths that occurred in a randomized multicenter trial. The long-term effects of aspirin plus dipyridamole on major vascular outcome variables were studied in 231 non insulin-dependent diabetic men with either a recent amputation for gangrene or active gangrene. Depending upon the definition of sudden death used, there were 14, 22, or 17 deaths in the drug group versus 6, 6, or 3 deaths in the placebo group (p = 0.04, 0.001, or 0.001, respectively). Total deaths from atherosclerotic vascular disease or deaths from all causes did not differ in the two treatment groups. Since this finding of a secondary end point is found only after multiple analyses of the data, it must be interpreted with caution. However, it is suggested that further studies on effects of antiplatelet agents on sudden deaths should be performed.

The effect of clomipramine treatment on plasma lipoproteins and high density lipoprotein subfractions in healthy subjects

The effect of clomipramine on plasma lipoproteins, including high density lipoprotein (HDL) subfractions in five healthy males was investigated. The concentrations of total plasma cholesterol and low density lipoprotein cholesterol decreased slightly while that of total HDL-cholesterol showed a small increase, giving a decrease (p less than 0.05) in the ratio of total plasma cholesterol to HDL-cholesterol. The level of HDL2-cholesterol increased (p less than 0.01) with clomipramine treatment while there was no significant change in the concentration of HDL3-cholesterol. Gradient gel electrophoresis showed that administration of the drug was associated with an increase in the relative concentration of HDL2a as well as of HDL2b and a decrease in that of HDL3b/3c. The plasma concentration of apolipoprotein (Apo) A-I showed a small but insignificant increase. These changes in lipoprotein profile are characteristic of those associated with a decrease in coronary risk.

Research links between psychiatry and cardiology. Hypertension, type A behavior, sudden death, and the physiology of emotional arousal

Psychiatrists and cardiologists have collaborated in clinical care and research for decades. This article reviews some of the current areas of mutual interest, with special attention focused on research on behavior and hypertension, type A behavior pattern, sudden death, and the physiology of emotional arousal. In clinical care and epidemiologic and physiologic research, there are numerous issues at the cutting edge of knowledge that will be clarified by continued collaboration.

Identification of persons at risk for sudden cardiac death

Before any more progress is made in reducing the incidence of sudden cardiac death, our ability to identify those at risk must be refined further. The close association with coronary artery disease necessitates that the first step must be the identification of those with underlying coronary artery disease. This is underscored by the disturbing fact that, in many, sudden death is the first sign of coronary disease. An aggressive evaluation of those with significant risk factors appears justified. The second part of the problem is the identification of those with coronary artery disease who are at especially high risk. The current diagnostic modalities available suffer from a relative lack of specificity to be applied indiscriminately in light of the expense and morbidity of effective therapies (that is, coronary artery bypass surgery, antiarrhythmic drugs, implantable defibrillators, surgical or catheter ablation). At the present time, we can identify certain subsets that warrant aggressive therapy: survivors of sudden death events or sustained ventricular tachycardia, obstructive cardiomyopathies, aortic stenosis, left main coronary artery disease, and congenital QT prolongation. Less aggressive but also less specific therapies, such as beta-blockers in myocardial infarction survivors, can be given more indiscriminately. Ultimately, of course, the greatest impact will come from prevention of coronary artery disease.

Benefits and risks of menopausal estrogen and/or progestin hormone use

Current evidence is reviewed here on risks and benefits of estrogen and progestin use by peri- and postmenopausal women in relation to the following conditions: endometrial cancer, breast cancer, osteoporosis, and coronary artery disease (CAD). On balance, estrogen therapy appears to be beneficial for menopausal women, as it probably reduces the risks of CAD and osteoporosis, two of the major causes of mortality and morbidity. Although unopposed estrogen therapy increases the risk of endometrial cancer, that cancer is relatively rare and is not fatal in the vast majority of cases associated with estrogen use. Definitive conclusions about the relation of menopausal estrogens to breast cancer cannot be drawn due to inconsistent evidence to date. Although evidence from randomized controlled trials is lacking, biochemical and clinical evidence suggest that progestin supplementation is associated with a reduction in endometrial cancer risk in women taking menopausal estrogens. Progestin supplementation also may augment the beneficial effects of estrogens in providing protection against osteoporosis, although this effect is not yet well established. There is little direct evidence bearing on the relation of menopausal progestins to breast cancer. Although studies of CAD per se are lacking at present, progestins probably unfavorably alter lipoprotein profiles, thereby increasing a user's risk of CAD. Given the relatively high incidence and mortality of CAD in postmenopausal women, any negative effects on CAD risk could potentially counterbalance beneficial effects on other causes. We conclude that estrogen replacement therapy is of potential benefit to postmenopausal women, but that the question of progestin supplementation requires further study, particularly for CAD risk.

Pregnancy-associated inhibition of coronary artery atherosclerosis in monkeys. Evidence of a relationship with endogenous estrogen

We investigated the influence of repeated pregnancy on diet-induced atherosclerosis in cynomolgus monkeys and sought to determine if circulating endogenous reproductive steroid levels were associated with the extent of coronary artery atherosclerosis. At necropsy, females which were pregnant one or more times were found to have coronary artery atherosclerosis which was one-fourth as extensive as that of intact females which had not been pregnant. Extent of coronary artery atherosclerosis correlated positively with mean total plasma cholesterol (Rho = 0.52, p less than 0.01) and inversely with high density lipoprotein (HDL) cholesterol (Rho = -0.48, p less than 0.01) concentrations; both decreased during pregnancy. Additionally, the extent of coronary artery atherosclerosis was found to have a strong inverse association (Rho = -0.66, p less than 0.001) with an index (area-under-the-curve) of magnitude and duration of the pregnancy-induced elevation in plasma 17-beta estradiol concentration. This association could not be explained by an interrelationship between estradiol area-under-the-curve and either plasma total or HDL cholesterol concentrations. There was no relationship between atherosclerosis extent and a similar index of plasma progesterone concentrations. These findings provide evidence for an inhibitory effect of endogenous estrogen on the progression of coronary artery atherosclerosis.

Fluctuations of plasma lipoprotein-A concentrations during pregnancy and post partum

The changes in plasma lipoprotein-a Lp-a concentrations during pregnancy were investigated. Out of 42 women with normal pregnancy, 22 reached Lp-a values greater than 10 mg/dL. Plasma levels of Lp-a in addition to total cholesterol, and apolipoprotein B were measured at 4 to 6-week intervals during pregnancy and post partum. The hormones hCG, human placenta lactogen, progesterone, estradiol, and insulin were measured concomitantly. The results can be summarized as follows: Plasma Lp-a concentrations rose steadily during the first trimester of pregnancy and reached a maximum in the middle of the second trimester. Maximal Lp-a values in the 19th week on average were 2.8 times higher as compared to the values of the eight week of pregnancy. Plasma Lp-a fell from the 19th week of pregnancy, reaching a basal value at the time of birth. This value remained virtually unchanged until 6 months post partum. Despite the fact that apolipoprotein-B and total cholesterol rose significantly, exhibiting pronounced maxima during the course of pregnancy, there was no overlap in the shape of their concentration curve with Lp-a. The rise in plasma Lp-a concentration did not correlate with any of the measured hormones at a given time interval. Time shifted analysis of the concentration curve revealed a correlation with hCG, however, with a lag phase of approximately 11 weeks. This study substantiates the independent metabolic control of Lp-a, as compared to plasma apolipoprotein-B and total cholesterol.

Socioeconomic factors and physical activity in relation to cardiovascular disease and death. A 12 year follow up of participants in a population study of women in Gothenburg, Sweden

In a prospective population study of middle aged women socioeconomic factors and physical activity as initially reported were related to the 12 year incidence of ischaemic heart disease and to total mortality. There was a significant age specific correlation between low socioeconomic status according to the husband's occupation and myocardial infarction. No such association was seen between the socioeconomic status of the women themselves and myocardial infarction. Women with a low educational level had a significantly increased age specific incidence of angina pectoris. There was no significant correlation between marital status or number of children and incidence of ischaemic heart disease or overall mortality. Women who initially reported low physical activity at work during the last year had a significantly increased age specific 12 year incidence of stroke and death, as did those who reported low physical activity during leisure hours in whom the incidence of myocardial infarction and electrocardiographic changes indicating ischaemic heart disease were also increased. Multivariate analyses showed that the association between low educational level and incidence of angina pectoris was independent of socioeconomic group, smoking habits, systolic blood pressure, indices of obesity, serum triglycerides, and serum cholesterol. Similarly, low physical activity during leisure hours seemed to be an independent risk factor for stroke, and low physical activity at work was an independent risk factor for overall mortality.

Risk factors for sudden unexpected cardiac death in young women in Rochester, Minnesota, 1960 through 1974

A case-control study of sudden unexpected death (SUD) as the initial manifestation of coronary heart disease in women younger than 60 years of age was conducted in Rochester, Minnesota. Risk factors among the 15 SUD cases identified during the years 1960 through 1974 were compared with those in two control groups--a population group of 60 (4 age-matched controls per case) and the 59 cases of myocardial infarction diagnosed in women younger than 60 years of age in Rochester during the same period. By using Miettinen's matched analysis for comparison of SUD cases and matched controls, the relative risks for the accepted coronary heart disease risk factors of ever smoking and hypertension were 8.6 (95% confidence interval [CI], 1.3 to 57.3) and 5.7 (95% CI, 1.2 to 26.9), respectively. In a comparison of SUD cases and myocardial infarction cases by using the Mantel-Haenszel procedure and stratifying by five age groups, the odds ratios were 1.2 for ever smoking and 0.8 for hypertension. Six of the 15 SUD cases had a diagnosis of alcoholism compared with 2 of the 60 controls and 4 of the 59 myocardial infarction cases; thus, the relative risks were 12.0 (95% CI, 3.4 to 41.9) and 4.8 (95% CI, 1.3 to 18.2), respectively. Ever married SUD cases were nulliparous or had fewer children more often than the controls or the myocardial infarction cases. The combination of major psychiatric diagnosis and major tranquilizer use occurred with greater frequency among SUD cases than among controls (relative risk, 2.9; 95% CI, 0.6 to 14.1), whereas comparison of SUD cases and myocardial infarction cases for this variable resulted in a relative risk of 0.7 (95% CI, 0.3 to 1.9).

Role of emotions and stress in the genesis of sudden death

Emotional arousal induces dramatic endocrine responses through either the sympathetic-adrenal medullary system or pituitary-adrenal cortical system. Many of the known actions of cortisol and catecholamines are atherogenic, cardiotoxic and arrhythmogenic. Emotional stress can produce sudden cardiac death in experimental animals, as can the administration of exogenous catecholamines. Previous studies have found that emotional stress is a common precursor to sudden cardiac death. Thus, acute neuroendocrine arousal, superimposed on a substrate of compromised myocardium and electrical instability, may constitute an important, final inciting event in sudden cardiac death.

Psychosocial predictors of sudden death: a review and critique

Research and selected case studies concerning psychosocial prediction of sudden death are evaluated under three categories: sudden cardiac, sudden infant and sudden traumatic death. The psychosocial predictors reviewed include novelty-pre-exposure, control-helplessness, restraint, Type A behavior, life change, bereavement, denial, social support and contact, voodoo, psychiatric illness, mother infant separation, submission-defeat, housing, handling and environmental enrichment. Four of these predictors, controllability-helplessness, pre-exposure-novelty, depressive affect and physical restraint are repeatedly cited in both human and animal studies and their importance is critically evaluated. Methodological and substantive recommendations for future research are made and a discussion of possible mechanisms is presented.

Mortality of a lithium-treated population

In South-East Scotland, 791 subjects treated with lithium for more than two months during 1967-76 were traced, using public and health service records; 751 were traced alive, 33 had died, and seven remained untraced. The standardised mortality rate was 2.83, and excess mortality was attributable to suicide (increased 36-times) and cardiovascular disease (increased 2.15-times); deaths from nephropathy, cancer or leukaemia were not increased. Comparison of the 33 deaths and 33 matched patients, selected from the 751 survivors, showed that patients dying on lithium were similar in most respects to survivors, but when first starting lithium, they had more signs of physical disease.

Sudden unexpected cardiac death--a practical approach to the forensic problem

Sudden cardiac death can usually be resolved by the pathologist into ischaemic heart disease, non-vascular cardiac disease such as aortic stenosis or hypertrophic obstructive cardiomyopathy and infrequently a morphologically normal heart on naked eye examination. When ischaemic heart disease is present one third of cases have a recent occlusive coronary artery thrombosis. Two thirds of patients have coronary stenosis only; the minimum degree of disease reasonably associated with sudden death is one area of 85% stenosis. The majority of patients, however, have multiple areas of stenosis. The predominant causes of non-ischaemic sudden death are severe LV hypertrophy, hypertrophic obstructive cardiomyopathy and the prolapsing mitral valve syndrome. Where the heart and coronary arteries are morphologically normal, review of any previous ECG's, a family history and histological examination of the myocardium and conduction system may reveal a cause or at least allow a reasonable assumption of cardiac arrhythmia to be made. Sudden unexpected death where the circumstances strongly suggest a cardiac cause may pose problems for the pathologist. Ischaemic heart disease (coronary atherosclerosis) is undoubtedly the most frequent cause but even when this is so the detailed pathology is controversial. It is when coronary artery disease is conspicuously absent, often in young individuals previously in good health, that a problem exists. Sudden death in infancy (cot death) is a different entity with its own problems and is not here discussed further.