Rising adiposity curbing decline in the incidence of myocardial infarction: 20-year follow-up of British men and women in the Whitehall II cohort

Temporal trend in dementia incidence since 2002 and projections for prevalence in England and Wales to 2040: modelling study

Objective To forecast dementia prevalence with a dynamic modelling approach that integrates calendar trends in dementia incidence with those for mortality and cardiovascular disease.Design Modelling study.Setting General adult population of England and Wales.Participants The English Longitudinal Study of Ageing (ELSA) is a representative panel study with six waves of data across 2002-13. Men and women aged 50 or more years, selected randomly, and their cohabiting partners were recruited to the first wave of ELSA (2002-03). 11392 adults participated (response rate 67%). To maintain representativeness, refreshment participants were recruited to the study at subsequent waves. The total analytical sample constituted 17 906 people. Constant objective criteria based on cognitive and functional impairment were used to ascertain dementia cases at each wave.Main outcome measures To estimate calendar trends in dementia incidence, correcting for bias due to loss to follow-up of study participants, a joint model of longitudinal and time-to-event data was fitted to ELSA data. To forecast future dementia prevalence, the probabilistic Markov model IMPACT-BAM (IMPACT-Better Ageing Model) was developed. IMPACT-BAM models transitions of the population aged 35 or more years through states of cardiovascular disease, cognitive and functional impairment, and dementia, to death. It enables prediction of dementia prevalence while accounting for the growing pool of susceptible people as a result of increased life expectancy and the competing effects due to changes in mortality, and incidence of cardiovascular disease.Results In ELSA, dementia incidence was estimated at 14.3 per 1000 person years in men and 17.0/1000 person years in women aged 50 or more in 2010. Dementia incidence declined at a relative rate of 2.7% (95% confidence interval 2.4% to 2.9%) for each year during 2002-13. Using IMPACT-BAM, we estimated there were approximately 767 000 (95% uncertainty interval 735 000 to 797 000) people with dementia in England and Wales in 2016. Despite the decrease in incidence and age specific prevalence, the number of people with dementia is projected to increase to 872 000, 1 092 000, and 1 205 000 in 2020, 2030, and 2040, respectively. A sensitivity analysis without the incidence decline gave a much larger projected growth, of more than 1.9 million people with dementia in 2040.Conclusions Age specific dementia incidence is declining. The number of people with dementia in England and Wales is likely to increase by 57% from 2016 to 2040. This increase is mainly driven by improved life expectancy.

Social factors and cardiovascular morbidity

Recent progress in population health at aggregate level, measured by life expectancy, has been accompanied by lack of progress in reducing the difference in health prospects between groups defined by social status. Cardiovascular disease is an important contributor to this undesirable situation. The stepwise gradient of higher risk with lower status is accounted for partly by social gradients in health behaviors. The psychosocial hypothesis provides a stronger explanation, based on social patterning of living and working environments and psychological assets that individuals develop during childhood. Three decades of research based on Whitehall II and other cohort studies provide evidence for psychosocial pathways leading to cardiovascular morbidity and mortality. Job stress is a useful paradigm because exposure is long term and depends on occupational status. Studies of social-biological translation implicate autonomic and neuroendocrine function among the biological systems that mediate between chronic adverse psychosocial exposures and increased cardiometabolic risk and cardiovascular disease incidence.

Impact of variants in CETP and apo AI genes on serum HDL cholesterol levels in men and women from the Polish population

INTRODUCTION

Polymorphisms in the cholesterol ester transfer protein (CETP) gene and apolipoprotein AI (apo AI) gene are identified as the most common genetic factors influencing high-density lipoprotein cholesterol (HDL cholesterol) levels. Low HDL cholesterol is an important risk factor for cardiovascular disease. We investigated the effect of the TaqIB polymorphism of the CETP gene and the 75G/A polymorphism of the apo AI gene on the HDL cholesterol concentration in a sample of Polish adults.

MATERIAL AND METHODS

A total of 621 subjects, 414 women and 207 men, were included in this study. Lipid levels were measured using standard protocols, and apolipoprotein AI was determined by immunoturbidimetric assay. CETP and apo AI genotyping was performed using a restriction fragment length polymorphism based method.

RESULTS

Significantly lower HDL cholesterol concentrations were found in B1B1 homozygotes than in carriers of the B2 allele of the TaqIB polymorphism in the CETP gene among both men and women. In GG homozygotes of the 75G/A polymorphism in the apo AI gene lower HDL cholesterol levels were observed, but the difference did not reach statistical significance. A statistically significant association of low HDL cholesterol (< 25th percentile) with CETP genotypes was found in women (p < 0.0001) and in men (p = 0.0368).

CONCLUSIONS

These data demonstrate a significant impact of the TaqIB polymorphism in the CETP gene on HDL cholesterol levels in the studied Polish population, while the effect of the 75G/A polymorphism in the apo AI gene appears not to be significant.

Ischemic Stroke Rate Increases in Young Adults: Evidence for a Generational Effect?

BACKGROUND

The incidence rates of ischemic stroke and ST-segment elevation myocardial infarction (STEMI) have decreased significantly in the United States since 1950. However, there is evidence of flattening of this trend or increasing rates for stroke in patients younger than 50 years. The objective of this study was to examine the changes in incidence rates of stroke and STEMI using an age-period-cohort model with statewide data from New Jersey.

METHODS AND RESULTS

We obtained stroke and STEMI data for the years 1995-2014 from the Myocardial Infarction Data Acquisition System, a database of hospital discharges in New Jersey. Rates by age for the time periods 1994-1999, 2000-2004, 2005-2009, and 2010-2014 were obtained using census estimates as denominators for each age group and period. The rate of stroke more than doubled in patients aged 35 to 39 years from 1995-1999 to 2010-2014 (rate ratio [RR], 2.47; 95% CI, 2.07-2.96 [P<0.0001]). We also found increased rates of stroke in those aged 40 to 44, 45 to 49, and 50 to 54 years. Strokes rates in those older than 55 years decreased during these time periods. Those born from 1945-1954 had lower age-adjusted rates of stroke than those born both in the prior 20 years and in the following 20 years. STEMI rates, in contrast, decreased in all age groups and in each successive birth cohort.

CONCLUSIONS

There appears to be a significant birth cohort effect in the risk of stroke, where patients born from 1945-1954 have lower age-adjusted rates of stroke compared with those born in earlier and later years.

Trends in Coronary Atherosclerosis: A Tale of Two Population Subgroups

BACKGROUND

We previously investigated trends in subclinical coronary artery disease and associated risk factors among autopsied non-elderly adults who died from nonnatural causes. Although grade of atherosclerosis declined from 1981 through 2009, the trend was nonlinear, ending in 1995, concurrent with increasing obesity/diabetes in this population. The previous study used linear regression and examined trends for all 4 major epicardial coronary arteries combined. The present investigation of coronary artery disease trends for the period 1995 through 2012 was prompted by a desire for more detailed examination of more recent coronary artery disease trends in light of reports that the epidemics of obesity and diabetes have slowed and are perhaps ending.

METHODS

This population-based series of cross-sectional investigations identified all Olmsted County, Minnesota residents aged 16-64 years who died 1995 through 2012 (N = 2931). For decedents with nonnatural manner of death, pathology reports were reviewed for grade of atherosclerosis assigned each major epicardial coronary artery. Using logistic regression, we estimated calendar-year trends in grade (unadjusted and age- and sex-adjusted) for each artery, initially as an ordinal measure (range, 0-4); then, based on evidence of nonproportional odds, as a dichotomous variable (any atherosclerosis, yes/no) and as an ordinal measure for persons with atherosclerosis (range, 1-4).

RESULTS

Of 474 nonnatural deaths, 453 (96%) were autopsied; 426 (90%) had coronary stenosis graded. In the ordinal-logistic model for trends in coronary artery disease grade (range, 0-4), the proportional odds assumption did not hold. In subsequent analysis as a dichotomous outcome (grades 0 vs 1-4), each artery exhibited a significant temporal decline in the proportion with any atherosclerosis. Conversely, for subjects with coronary artery disease grade 1-4, age- and sex-adjusted ordinal regression revealed no change over time in 2 arteries and statistically significant temporal increases in severity in 2 arteries.

CONCLUSIONS

Findings suggest that efforts to prevent coronary artery disease onset have been relatively successful. However, statistically significant increases in the grade of atherosclerosis in 2 arteries among persons with coronary artery disease may be indicative of a major public health challenge.

Comparative safety and efficacy of statins for primary prevention in human immunodeficiency virus-positive patients: a systematic review and meta-analysis

The efficacy and safety of different statins for human immunodeficiency virus (HIV)-positive patients in the primary prevention setting remain to be established. In the present meta-analysis, 18 studies with 736 HIV-positive patients receiving combination antiretroviral therapy (cART) and treated with statins in the primary prevention setting were included (21.0% women, median age 44.1 years old). The primary endpoint was the effect of statin therapy on total cholesterol (TC) levels. Rosuvastatin 10 mg and atorvastatin 10 mg provided the largest reduction in TC levels [mean -1.67, 95% confidence interval (CI) (-1.99, -1.35) mmol/L; and mean -1.44, 95% CI (-1.85, -1.02) mmol/L, respectively]. Atorvastatin 80 mg and simvastatin 20 mg provided the largest reduction in low-density lipoprotein (LDL) [mean -2.10, 95% CI (-3.39, -0.81) mmol/L; and mean -1.57, 95% CI (-2.67, -0.47) mmol/L, respectively]. Pravastatin 10-20 mg [mean 0.24, 95% CI (0.10, 0.38) mmol/L] and atorvastatin 10 mg [mean 0.15, 95% CI (0.007, 0.23) mmol/L] had the largest increase in high-density lipoprotein, whereas atorvastatin 80 mg [mean -0.60, 95% CI (-1.09, -0.11) mmol/L] and simvastatin 20 mg [mean -0.61, 95% CI (-1.14, -0.08) mmol/L] had the largest reduction in triglycerides. The mean discontinuation rate was 0.12 per 100 person-years [95% CI (0.05, 0.20)], and was higher with atorvastatin 10 mg [26.5 per 100 person-years, 95% CI (-13.4, 64.7)]. Meta-regression revealed that nucleoside reverse transcriptase inhibitors-sparing regimens were associated with reduced efficacy for statin's ability to lower TC. Statin therapy significantly lowers plasma TC and LDL levels in HIV-positive patients and is associated with low rates of adverse events. Statins are effective and safe when dose-adjusted for drug-drug interactions with cART.

Contributions of increasing obesity and diabetes to slowing decline in subclinical coronary artery disease

Background

Our previous study of nonelderly adult decedents with nonnatural (accident, suicide, or homicide) cause of death (96% autopsy rate) between 1981 and 2004 revealed that the decline in subclinical coronary artery disease (CAD) ended in the mid‐1990s. The present study investigated the contributions of trends in obesity and diabetes mellitus to patterns of subclinical CAD and explored whether the end of the decline in CAD persisted.

Methods and Results

We reviewed provider‐linked medical records for all residents of Olmsted County, Minnesota, who died from nonnatural causes within the age range of 16 to 64 years between 1981 and 2009 and who had CAD graded at autopsy. We estimated trends in CAD risk factors including age, sex, systolic blood pressure, diabetes (qualifying fasting glucose or medication), body mass index, smoking, and diagnosed hyperlipidemia. Using multiple regression, we tested for significant associations between trends in CAD risk factors and CAD grade and assessed the contribution of trends in diabetes and obesity to CAD trends. The 545 autopsied decedents with recorded CAD grade exhibited significant declines between 1981 and 2009 in systolic blood pressure and smoking and significant increases in blood pressure medication, diabetes, and body mass index ≥30 kg/m². An overall decline in CAD grade between 1981 and 2009 was nonlinear and ended in 1994. Trends in obesity and diabetes contributed to the end of CAD decline.

Conclusions

Despite continued reductions in smoking and blood pressure values, the previously observed end to the decline in subclinical CAD among nonelderly adult decedents was apparent through 2009, corresponding with increasing obesity and diabetes in that population.

Characteristics and outcome among patients who dial for the EMS due to chest pain

OBJECTIVES

This study aims to describe patients who called for the emergency medical service (EMS) due to chest discomfort, in relation to gender and age.

METHODS

All patients who called the emergency dispatch centre of western Sweden due to chest discomfort, between May 2009 and February 2010, were included. Initial evaluation, aetiology and outcome are described as recorded in the databases at the dispatch centre, the EMS systems and hospitals. Patients were divided into the following age groups: ≤50, 51-64 and ≥65 years.

RESULTS

In all, 14,454 cases were enrolled. Equal proportions of men (64%) and women (63%) were given dispatch priority 1. The EMS clinicians gave priority 1 more frequently to men (16% versus 12%) and older individuals (10%, 15% and 14%, respective of age group). Men had a significantly higher frequency of central chest pain (83% versus 81%); circulatory compromise (34% versus 31%); ECG signs of ischaemia (17% versus 11%); a preliminary diagnosis of acute coronary syndrome (40% versus 34%); a final diagnosis of acute myocardial infarction (14% versus 9%) and any potentially life-threatening condition (18% versus 12%). Individuals aged ≥65 years were given a lower priority than individuals aged 51-64 years, despite poorer characteristics and outcome. In all, 78% of cases with a potentially life-threatening condition and 67% of cases that died within 30 days of enrolment received dispatch priority 1. Mortality at one year was 1%, 4% and 18% in each individual age group.

CONCLUSION

Men and the elderly were given a disproportionately low priority by the EMS.

The importance of audit to monitor applications of procedures and improve primary angioplasty results

Although clinical trials have demonstrated that primary percutaneous coronary intervention (PPCI) provides better outcomes than thrombolysis for STEMI, it cannot be assumed that similar results can be obtained in day-to-day practice. To determine whether standards are being met, continuous audit of PPCI programmes is necessary, with appropriate feedback to participating centres and operators. Both the MINAP and BCIS national audit projects allow central electronic collection of data on consecutive patients presenting to every hospital involved in the acute management of these patients. Regular programmed feedback is provided to centres performing primary PCI that attempts to take account of statistical variation and differences in case mix between units by making use of funnel plots, statistical process control graphs and risk adjustment models. This reporting of "process" and "outcome" data, both confidentially and within the public domain, has been used to drive up clinical performance and has been associated with steady improvements and reduced inequalities of care.

Association of body mass index and waist circumference with successful aging

OBJECTIVE

The prediction of successful aging by midlife body mass index (BMI) and waist circumference (WC) was examined.

METHODS

BMI/WC were assessed in 4869 persons (mean age 51.2, range 42-63 in 1991/1993) and survival and successful aging (alive, no chronic disease at age >60 years, not in the worst age- and sex-standardized quintile of cognitive, physical, respiratory,cardiovascular, and mental health) ascertained over a 16-year follow-up, analyzed using logistic regression adjusted for sociodemographic factors and health behaviors.

RESULTS

507 participants died, 1008 met the criteria for successful aging. Those with BMI ≥ 30 kg/m(2) had lower odds of successful aging (odds ratio or OR) = 0.37; 95% confidence interval or CI: 0.27, 0.50) and survival (OR = 0.55; 95% CI: 0.41, 0.74) compared to BMI between 18.5 and 25 kg/m(2) . Those with a large WC (≥102/88 cm in men/women) had lower odds of successful aging (OR = 0.41; 95% CI: 0.31, 0.54) and survival (OR = 0.57; 95% CI: 0.44, 0.73) compared with those with a small waist (<94/80 cm in men/women). Analysis with finer categories showed lower odds of successful aging starting at BMI ≥ 23.5 kg/m(2) and WC 82/68 cm in men/women.

CONCLUSIONS

Optimal midlife BMI and WC for successful aging might be substantially below the current thresholds used to define obesity.

Contribution of modifiable risk factors to social inequalities in type 2 diabetes: prospective Whitehall II cohort study

OBJECTIVE

To assess the contribution of modifiable risk factors to social inequalities in the incidence of type 2 diabetes when these factors are measured at study baseline or repeatedly over follow-up and when long term exposure is accounted for.

DESIGN

Prospective cohort study with risk factors (health behaviours (smoking, alcohol consumption, diet, and physical activity), body mass index, and biological risk markers (systolic blood pressure, triglycerides and high density lipoprotein cholesterol)) measured four times and diabetes status assessed seven times between 1991-93 and 2007-09.

SETTING

Civil service departments in London (Whitehall II study).

PARTICIPANTS

7237 adults without diabetes (mean age 49.4 years; 2196 women).

MAIN OUTCOME MEASURES

Incidence of type 2 diabetes and contribution of risk factors to its association with socioeconomic status.

RESULTS

Over a mean follow-up of 14.2 years, 818 incident cases of diabetes were identified. Participants in the lowest occupational category had a 1.86-fold (hazard ratio 1.86, 95% confidence interval 1.48 to 2.32) greater risk of developing diabetes relative to those in the highest occupational category. Health behaviours and body mass index explained 33% (-1% to 78%) of this socioeconomic differential when risk factors were assessed at study baseline (attenuation of hazard ratio from 1.86 to 1.51), 36% (22% to 66%) when they were assessed repeatedly over the follow-up (attenuated hazard ratio 1.48), and 45% (28% to 75%) when long term exposure over the follow-up was accounted for (attenuated hazard ratio 1.41). With additional adjustment for biological risk markers, a total of 53% (29% to 88%) of the socioeconomic differential was explained (attenuated hazard ratio 1.35, 1.05 to 1.72).

CONCLUSIONS

Modifiable risk factors such as health behaviours and obesity, when measured repeatedly over time, explain almost half of the social inequalities in incidence of type 2 diabetes. This is more than was seen in previous studies based on single measurement of risk factors.

Interventions to promote an integrated approach to public health problems: an application to childhood obesity

Experts stress the need to bring the childhood obesity epidemic under control by means of an integrated approach. The implementation of such an approach requires the development of integrated enabling policies on public health by local governments. A prerequisite for developing such integrated public health policies is intersectoral collaboration. Since the development of integrated policies is still in its early stages, this study aimed to answer the following research question: "What interventions can promote intersectoral collaboration and the development of integrated health policies for the prevention of childhood obesity?" Data were collected through a literature search and observations of and interviews with stakeholders. Based on a theoretical framework, we categorized potential interventions that could optimize an integrated approach regarding children's physical activity and diet. The intervention categories included education, persuasion, incentivization, coercion, training, restriction, environmental restructuring, modeling, and enablement.

Weight change and lipoprotein particle concentration and particle size: a cohort study with 6.5-year follow-up

OBJECTIVE

Obesity and overweight are related to unfavourable lipoprotein subclass profiles. Here we studied the relation between weight change and lipoprotein particle concentrations and sizes in a general population cohort in a longitudinal setting.

METHODS

The cohort included 683 adults with a 6.5-year follow-up. Lipoprotein particle subclasses and mean particle sizes of VLDL, LDL, and HDL were measured by nuclear magnetic resonance spectroscopy.

RESULTS

During the follow-up period, a weight loss of at least 5% was associated with decreased particle concentrations of all apoB-containing subclasses and increased concentrations of large HDL particles. Coherently, weight gain (≥5%) was associated with increases in all apoB-containing subclasses and decreases in total and medium HDL particle concentrations. The relatively largest increase occurred for large HDL particle concentration (24.1%, 95% CI 15.8-32.5) in weight loss and for large VLDL particle concentration (33.0%, 19.6-46.4) in weight gain. Weight change correlated positively with changes in apoB-containing lipoprotein particle concentrations and also with the change in average VLDL particle size. Negative correlations were found between weight change and the change in average LDL (r = -0.10) and HDL (r = -0.32) particle size, but not between weight change and total HDL particle concentration.

CONCLUSION

Moderate weight loss is related to favourable and weight gain to unfavourable changes in lipoprotein subclass profiles. These population level findings underline the importance of weight control as a modifier of cardiovascular risk factors.

Coding, recording and incidence of different forms of coronary heart disease in primary care

Objectives

To evaluate the coding, recording and incidence of coronary heart disease (CHD) in primary care electronic medical records.

Methods

Data were drawn from the UK General Practice Research Database. Analyses evaluated the occurrence of 271 READ medical diagnostic codes, including categories for ‘Angina’, ‘Myocardial Infarction’, ‘Coronary Artery Bypass Grafting’ (CABG), ‘percutaneous transluminal coronary angioplasty’ (PCTA) and ‘Other Coronary Heart Disease’. Time-to-event analyses were implemented to evaluate occurrences of different groups of codes after the index date.

Results

Among 300,020 participants aged greater than 30 years there were 75,197 unique occurrences of coronary heart disease codes in 24,244 participants, with 12,495 codes for incident events and 62,702 for prevalent events. Among incident event codes, 3,607 (28.87%) were for angina, 3,262 (26.11%) were for MI, 514 (4.11%) for PCTA, 161 (1.29%) for CABG and 4,951 (39.62%) were for ‘Other CHD’. Among prevalent codes, 20,254 (32.30%) were for angina, 3,644 (5.81%) for MI, 34,542 (55.09%) for ‘Other CHD’ and 4,262 (6.80%) for CABG or PCTA. Among 3,685 participants initially diagnosed exclusively with ‘Other CHD’ codes, 17.1% were recorded with angina within 5 years, 5.6% with myocardial infarction, 6.3% with CABG and 8.6% with PCTA. From 2000 to 2010, the overall incidence of CHD declined, as did the incidence of angina, but the incidence of MI did not change. The frequency of CABG declined, while PCTA increased.

Conclusion

In primary care electronic records, a substantial proportion of coronary heart disease events are recorded with codes that do not distinguish between different clinical presentations of CHD. The results draw attention to the need to improve coding practice in primary care. The results also draw attention to the importance of code selection in research studies and the need for sensitivity analyses using different sets of codes.