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

A theoretical model of the role of brain stem nuclei in alcohol-mediated arrhythmogenesis in older adults

Uncertainty about the mechanism of alcohol-mediated arrhythmogenesis and the effect of alcohol use on arrhythmic risk among older adults is an increasing concern in light of population aging and recent reports that moderate alcohol consumption may protect older adults against coronary artery disease. In this review, a theoretical model of the role of brain stem nuclei in alcohol-mediated arrhythmogenesis in older adults is developed. The model is based on the hypothesis that the effects of alcohol on central autonomic pathways of cardiac control may alter the threshold for alcohol-mediated arrhythmogenesis among older adults. Findings from multiple lines of research including cellular, electrophysiological, epidemiological, experimental, and clinical studies in human, animal, and in vitro models were synthesized in developing the model. Suggestions for future research on the topic of alcohol-mediated arrhythmogenesis in older adults are offered.

Sudden cardiac death in the United States, 1989 to 1998

BACKGROUND

Sudden cardiac death (SCD) is a major clinical and public health problem.

METHODS AND RESULTS

United States (US) vital statistics mortality data from 1989 to 1998 were analyzed. SCD is defined as deaths occurring out of the hospital or in the emergency room or as "dead on arrival" with an underlying cause of death reported as a cardiac disease (ICD-9 code 390 to 398, 402, or 404 to 429). Death rates were calculated for residents of the US aged >/=35 years and standardized to the 2000 US population. Of 719 456 cardiac deaths among adults aged >/=35 years in 1998, 456 076 (63%) were defined as SCD. Among decedents aged 35 to 44 years, 74% of cardiac deaths were SCD. Of all SCDs in 1998, coronary heart disease (ICD-9 codes 410 to 414) was the underlying cause on 62% of death certificates. Death rates for SCD increased with age and were higher in men than women, although there was no difference at age >/=85 years. The black population had higher death rates for SCD than white, American Indian/Alaska Native, or Asian/Pacific Islander populations. The Hispanic population had lower death rates for SCD than the non-Hispanic population. From 1989 to 1998, SCD, as the proportion of all cardiac deaths, increased 12.4% (56.3% to 63.9%), and age-adjusted SCD rates declined 11.7% in men and 5.8% in women. During the same time, age-specific death rates for SCD increased 21% among women aged 35 to 44 years.

CONCLUSIONS

SCD remains an important public health problem in the US. The increase in death rates for SCD among younger women warrants additional investigation.

Arrhythmias and women

The incidence and risk factors for a variety of arrhythmias differ among men and women. Although symptomatic atrial reentrant tachycardias have a female predominance, the reverse is true for atrial fibrillation. Women have a lower incidence of sudden death. On the other hand, drug-induced torsades de pointes and symptomatic long QT syndrome have a female predominance. The incidence of arrhythmias seem to be increased during pregnancy. The mechanisms of these gender differences are unclear but may be related to hormonal effects and the shorter QT interval in men. Pharmacologic and nonpharmacologic therapy are equally efficacious in men and women.

Medical risks for women who drink alcohol

OBJECTIVE

To summarize for clinicians recent epidemiologic evidence regarding medical risks of alcohol use for women.

METHODS

MEDLINE and PsychINFO, 1990 through 1996, were searched using key words "women" or "woman," and "alcohol." MEDLINE was also searched for other specific topics and authors from 1980 through 1996. Data were extracted and reviewed regarding levels of alcohol consumption associated with mortality, cardiovascular disease, alcohol-related liver disease, injury, osteoporosis, neurologic symptoms, psychiatric comorbidity, fetal alcohol syndrome, spontaneous abortion, infertility, menstrual symptoms, breast cancer, and gynecologic malignancies. Gender-specific data from cohort studies of general population or large clinical samples are primarily reviewed.

MAIN RESULTS

Women develop many alcohol-related medical problems at lower levels of consumption than men, probably reflecting women's lower total body water, gender differences in alcohol metabolism, and effects of alcohol on postmenopausal estrogen levels. Mortality and breast cancer are increased in women who report drinking more than two drinks daily. Higher levels of alcohol consumption by women are associated with increased menstrual symptoms, hypertension, and stroke. Women who drink heavily also appear to have increased infertility and spontaneous abortion. Adverse fetal effects occur after variable amounts of alcohol consumption, making any alcohol use during pregnancy potentially harmful.

CONCLUSIONS

In general, advising nonpregnant women who drink alcohol to have fewer than two drinks daily is strongly supported by the epidemiologic literature, although specific recommendations for a particular woman should depend on her medical history and risk factors.

Sudden coronary death in women

OBJECTIVES

The objective of this study was to examine prospectively the incidence, predisposing cardiovascular conditions, and risk factors for sudden death in women compared with men.

METHODS AND RESULT

The study design was a prospective general population examination of a cohort of 2873 women for development of sudden coronary death in relation to antecedent overt coronary heart disease (CHD), cardiac failure, and risk factors for coronary heart disease. Participants were women aged 30 to 62 years participating in the Framingham Study, receiving routine biennial examinations for risk factors and cardiovascular conditions. Among women monitored over a period of 38 years, there were 750 initial coronary events, of which 94 (12%) were sudden cardiac deaths. Of the 292 CHD fatalities in women, 32% were sudden cardiac deaths and 37% of the women had a history of prior CHD. Sudden death incidence in women logged behind that in men by >10 years. However, above age 75 years, 17% of all CHD events in women were sudden deaths. Sudden death risk in women with CHD was half as high as in men if they had CHD. In both sexes, a myocardial infarction conferred twice the risk of angina. Cardiac failure escalated sudden death risk of women 5-fold but was only one fourth that of men with failure or CHD. Ventricular ectopy increased sudden death risk only in women without prior overt CHD. Except for diabetes, CHD risk factors imposed a lower sudden death risk in women than men. However, even in women, sudden death risk increased over a 17-fold range in relation to their burden of CHD risk factors.

CONCLUSIONS

Sudden death is a prominent feature of CHD in women as well as men, particularly in advanced age. A higher fraction of sudden deaths in women than men is unexpected occurring in the absence of prior overt CHD. It is subject to the same risk factors and as predictable in women as in men. However, at any level of multivariate risk, women are less vulnerable to sudden death than men.

Cardiovascular risk factors and behavior lifestyles of young women: implications from findings of the Bogalusa Heart Study

The primary purposes of this article are to highlight important issues related to cardiovascular risk factors and behavior life-styles in young women and to examine racial (black-white) differences in risk factors that relate to cardiovascular disease. In childhood, some girls show cardiovascular risk factors of higher blood pressure levels, dyslipidemia, and obesity, all of which continue into young adulthood. Factors that contribute to abnormal risk factors are a high-saturated fat diet, excess energy intake related to inactivity, and cigarette smoking. Trends of obesity are documented; and young white girls are continuing to use tobacco, more so than boys and black girls. Although the onset of clinical cardiovascular disease is delayed in women, the stage is set in childhood for the development of early cardiovascular risk.

Effects of ethanol on the contractile function of the heart: a review

Chronic ethanol consumption leads to a number of alterations in the contractile function of the heart and is a leading cause of cardiomyopathy. Ethanol also has an acute negative inotropic effect mediated by direct interaction with cardiac muscle cells, although this action is often masked by indirect actions resulting from enhanced release of catecholamines in vivo. This article reviews the effects of ethanol on the contractile function of the heart. The specific targets affected by ethanol in cardiac muscle cells are discussed in terms of potential mechanisms underlying the depressions of contractility resulting from both acute and chronic actions of ethanol.

Alcohol and the heart. How it helps, how it harms

Does regular consumption of alcohol protect against coronary artery disease but not against sudden death? In this article, Dr Sheehy examines several theories that have been proposed to explain the cardioprotective effect of ethanol and also reviews the factors related to sudden death in alcoholics.

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.

The autopsy and epidemiology--Olmsted County, Minnesota and Malmo, Sweden

The existence of high quality, population-based, medical data facilitates the practice of modern epidemiology with its concomitant benefits for clinical practice and public health policy. Two exceptional examples of such databases are provided by Malmo, Sweden, and Olmsted County, Minnesota. This paper outlines briefly the similarities between these two geographic entities, and focuses, in particular, on the central role of the autopsy in Olmsted County. Changing temporal and spatial patterns of autopsy are reviewed as well as two important related issues: the role of consent and the medico-legal autopsy. The paper concludes with a summary of some of the more noteworthy contributions of autopsy-based epidemiological research in Olmsted County, and offers several recommendations for the establishment of a select network of special population-based study areas. These epidemiological "laboratories", through the interchange of data and tissue specimens, could make significant contributions to the study of diseases both nationally and internationally. Their interactive efforts and high quality data bases would help to increase the efficiency of the expenditure of scarce societal resources in epidemiology and health care.

Resurrecting the autopsy: benefits and recommendations

Maintenance of high autopsy rates is associated with specific benefits, especially for clinical practice and for clinical and epidemiologic research. We have compiled and evaluated (on the basis of related costs and benefits) a comprehensive list of recommendations to resurrect the autopsy and reestablish it as a central contributor to medical practice, teaching, and research.

Ethanol causes epicardial coronary artery vasoconstriction in the intact dog

Ethanol produces in vitro vasoconstriction of coronary arteries and can precipitate angina in patients with coronary obstructive disease. To demonstrate the in vivo effect of ethanol on coronary dynamics, baseline measurements of left anterior descending (LAD) coronary artery dimension by quantitative angiography, hemodynamics, arterial and coronary sinus blood gases, and blood ethanol levels were obtained in 14 closed-chest mongrel dogs. Three ethanol levels were established by intravenous bolus followed by 1-hour maintenance infusions. All measurements made at baseline were recorded every 30 minutes. Phentolamine (5 mg i.v.) and nicardipine (0.15 mg/kg i.v.) were given to evaluate constrictor mechanisms. Blood ethanol levels achieved at 60, 120, and 180 minutes were 649 +/- 48, 1,285 +/- 81, and 2,546 +/- 130 micrograms/ml, respectively. LAD cross-sectional area was reduced significantly from control at the end of each of the three dosing periods (-24 +/- 5%, -40 +/- 3%, and -53 +/- 3%; p less than 0.004). alpha-Adrenergic blockade had no effect on LAD cross-sectional area, while nicardipine partially reversed the ethanol-induced vasoconstriction. No significant change in vessel cross-sectional area took place in control dogs. These data suggest that ethanol induces epicardial coronary artery vasoconstriction in dogs at clinically important blood levels. alpha-Adrenergic blockade does not alter or reverse ethanol-induced vasoconstriction, while calcium channel blockade appears to be an effective vasodilator of ethanol-constricted vessels.