Smoking is associated with higher cardiovascular risk in young women than in men: the Tecumseh Blood Pressure Study

Smoking and overweight associated with masked uncontrolled hypertension: a Hypertension Optimal Treatment (HOT) Sub-Study

PURPOSE

The Hypertension Optimal Treatment (HOT) Study investigated the relationship between target office diastolic blood pressure (BP) ≤80, ≤85 or ≤90 mmHg and cardiovascular morbidity and mortality in 18,790 patients aged 50-80 years. The home BP sub-study enrolled 926 patients and the aim was to clarify whether the separation into the BP target groups in the office prevailed in the out-of-office setting. The present study aimed to identify variables that characterised masked uncontrolled hypertension (MUCH) and white coat uncontrolled hypertension (WUCH).

MATERIAL AND METHODS

The sub-study participants took their home BP when office BP had been up titrated. The cut-off for normal or high BP was set to ≥135/85 mmHg at home and ≥140/90 mmHg in the office. We analysed data by using multivariate and stepwise multivariate logistic regression with home and office BP combinations as the dependent variables.

RESULTS

WUCH was associated with lower body mass index (BMI) (odds ratio (OR) 0.92, 95% confident intervals (CIs) 0.88-0.96, p < 0.001). MUCH was associated with smoking (OR 1.89, 95% CIs 1.25-2.86, p = 0.0025) and with lower baseline heart rate (OR 0.98, 95% CIs 0.97-0.99, p = 0.03) and higher BMI (OR 1.03, CIs 1.00-1.06, p = 0.04). MUCH remained associated with smoking (OR 2.76, 95% CIs 1.76-4.35, p < 0.0001) also when using ≥140/90 mmHg as the cut-off for both home and office BP. MUCH was also associated with higher BMI (OR 1.05, 95% CIs 1.01-1.09, p = 0.009) while WUCH was associated with lower BMI (OR 0.93, 95% CIs 0.90-0.97, p = 0.0005) when using ≥140/90 mmHg as a cut-off.

CONCLUSION

Our data support that 'reversed or masked' treated but uncontrolled hypertension (MUCH) is common and constitutes about 25% of treated hypertensive patients. This entity (MUCH) is rather strongly associated with current smoking and overweight while uncontrolled white coat (office) hypertension (WUCH) is associated with lower BMI.

Effects of cigarette smoking on blood lipids in Korean men: Cardiovascular and Metabolic Diseases Etiology Research Center cohort

BACKGROUND/AIMS

Cigarette smoking and abnormal blood lipids are major risk factors for cardiovascular disease. The results of previous studies on the relationship between cigarette smoking and dyslipidemia are controversial. In the present study, we investigated the independent association between cigarette smoking and blood lipid levels in a male Korean population.

METHODS

A total of 1,932 men aged from 30 to 64 years old participated in the Cardiovascular and Metabolic Diseases Etiology Research Center cohort study. Smoking history was obtained by in-person interviews. In all regression models, measurements of triglyceride levels were log-transformed.

RESULTS

Triglyceride levels were higher in current smokers than in never-smokers (median: 149 mg/dL vs. 115 mg/dL, p < 0.001) even after adjusting age, body mass index, alcohol intake, systolic blood pressure, fasting glucose, physical activity, and nutrition intake (β = 0.14, p < 0.001). We further divided people into heavy and light smokers using 20 pack-years as the cut-off. Higher triglyceride were found in current heavy smokers (β = 0.18, p < 0.001), current light smokers (β = 0.13, p < 0.001), as well as in past heavy smokers (β = 0.08, p = 0.037), as compared to never-smokers. Moreover, significantly lower high-density lipoprotein cholesterol (HDL-C) were observed in current heavy smokers (β = -2.27 mg/dL, p = 0.009).

CONCLUSION

Cigarette smoking is associated with higher triglyceride in Korean men, with the most dramatic effect seen in current smokers with a smoking history of more than 20 pack-years. HDL-C were also lower in current smokers with more than 20 pack-years.

Rationale and study design of the MyHEART study: A young adult hypertension self-management randomized controlled trial

Young adults (18-39 year-olds) with hypertension have a higher lifetime risk for cardiovascular disease. However, less than 50% of young adults achieve hypertension control in the United States. Hypertension self-management programs are recommended to improve control, but have been targeted to middle-aged and older populations. Young adults need hypertension self-management programs (i.e., home blood pressure monitoring and lifestyle modifications) tailored to their unique needs to lower blood pressure and reduce the risks and medication burden they may face over a lifetime. To address the unmet need in hypertensive care for young adults, we developed MyHEART (My Hypertension Education And Reaching Target), a multi-component, theoretically-based intervention designed to achieve self-management among young adults with uncontrolled hypertension. MyHEART is a patient-centered program, based upon the Self-Determination Theory, that uses evidence-based health behavior approaches to lower blood pressure. Therefore, the objective of this study is to evaluate MyHEART's impact on changes in systolic and diastolic blood pressure compared to usual care after 6 and 12 months in 310 geographically and racially/ethnically diverse young adults with uncontrolled hypertension. Secondary outcomes include MyHEART's impact on behavioral outcomes at 6 and 12 months, compared to usual clinical care (increased physical activity, decreased sodium intake) and to examine whether MyHEART's effects on self-management behavior are mediated through variables of perceived competence, autonomy, motivation, and activation (mediation outcomes). MyHEART is one of the first multicenter, randomized controlled hypertension trials tailored to young adults with primary care. The design and methodology will maximize the generalizability of this study. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03158051.

Sex Differences in the Management and 5-Year Outcome of Young Patients (<55 Years) with Acute Coronary Syndromes

BACKGROUND

Young women are usually protected against coronary artery disease due to hormonal and risk-factor profile. Previous studies have suggested poorer outcome in women hospitalized with acute coronary syndrome as compared with men. However, when adjusted for age and other risk factors, this difference does not remain significant. We compared the risk profile and outcome between young (≤55 years) women and men admitted with acute coronary syndrome.

METHODS

We analyzed clinical characteristics, management strategies, and outcomes of men and women ≤55 years of age enrolled in the biennial Acute Coronary Syndrome Israeli Surveys between 2000 and 2013.

RESULTS

Among 11,536 patients enrolled, 3949 (34%) were ≤55 years old (407 women, 3542 men). Women were slightly older (48.9 ± 5.7 vs 48.3 ± 5.5, P = .007) and suffered more from diabetes (34% vs 24%) and hypertension (47% vs 37%, P <.001 for both). Rates of prior myocardial infarction were high in both sexes (18% vs 21%). Women presented less often with ST-elevation myocardial infarction (50% vs 57%, P = .007) and with typical chest pain (73% vs 80%, P = .004), and had higher rates of Global Registry of Acute Coronary Events (GRACE) score ≥140 (19% vs 12%, P = .007). After adjustment for GRACE score, diabetes, and enrollment year, women had a lower likelihood to undergo coronary angiography during hospitalization (odds ratio 0.6, P = .007). Female sex was independently associated with higher risk of in-hospital mortality (hazard ratio [HR] 4.1; 95% confidence interval [CI], 1.15-14.0), 30-day major adverse cardiac and cerebral events (HR 2.1; 95% CI, 1.31-3.36), and 5-year mortality (HR 1.96; 95% CI, 1.3-2.8).

CONCLUSIONS

Young women admitted with acute coronary syndrome are a unique high-risk group that presents a diagnostic challenge for clinicians. Women receive less invasive therapy during hospitalization and have worse in-hospital and long-term outcomes.

The risk and burden of smoking related heart disease mortality among young people in the United States

PURPOSE

Although cigarette smoking remains the most common risk factor for heart disease among the young, few studies have explored the relationship of smoking with heart disease mortality risk among young people. This prospective study assesses the risk and burden of all heart disease (HD) and coronary heart disease (CHD) mortality associated with smoking among younger adults from a nationally representative sample of the United States.

METHOD

National Health Interview Survey respondents' data from 1997-2004 were linked to their death records through 2006. The analyses were restricted to individuals 18 to 44 years of age during follow up (n = 121,284). Cox proportional hazard ratios (HR) were estimated with adjustment for sample weights and design effects. Attributable fractions (AF) of smoking were calculated.

RESULTS

After controlling for age, race, body mass index, history of hypertension and diabetes, and leisure time physical activity, current smoking related CHD mortality HR was 14.6 [95 % confidence interval or CI, 3.3-64.9] for females and 3.6 [95 % CI, 1.2-10.4] for males. The HR for all HD mortality was 3.1 [95 % CI, 1.3-7.6] for females and 2.4 [95 % CI, 1.2-4.7] for males. The AF of smoking for CHD deaths for female and male were 0.58 and 0.54 respectively. The AF of all HD mortality was 0.31 for male and 0.32 for female. The mean estimates of all HD deaths attributable to smoking during 1997-2006 among this age group were 52,214, of which 45,147 were CHD deaths.

CONCLUSION

Even after adjustment for multiple risk factors and without addressing passive smoking, our result showed a strong relationship between smoking and HD and CHD mortality among young adults that is likely causal.

Association of high blood pressure with body mass index, smoking and physical activity in healthy young adults

Introduction:

The purpose of this study was to examine the associations between resting blood pressure (BP), smoking, physical activity (PA) and body mass index (BMI) in Greek young adults.

Materials and Methodology:

A standardised questionnaire and the Greek version of IPAQ-short were given to 1500 randomly selected health science students, in order to record smoking behaviour, PA status, BMI and resting BP. All healthy young adults aged 19-30 years old were eligible. The final size of the study cohort was 1249 students (522 men).

Results:

Males’ BP was 129.2/77.0 mmHg, significantly higher than the females’ values of 119.9/73.4 mmHg. Approximately 17% of the total population were classified as overweight and 3% as obese. In the overall population, smoking prevalence was 35.2%, with 15.3% being heavy smokers (≥21 cigs/d). Smoking prevalence did not differ significantly between sexes. The prevalence of health-enhancing PA (high PA_class) was only 14.0%, while 42.8% of the study population were classified as insufficiently active (low PA_class). Of the three lifestyle risk factors examined, only BMI was significantly and directly associated with systolic and diastolic BP levels. The prevalence of hypertension (≥140/90 mmHg) was significantly higher in men compared to women, and in obese and overweight participants compared to normal-weight subjects. Smoking and categorical PA (PA_class) were not correlated with BP. Continuous vigorous PA_score was significantly and directly associated with systolic BP, but only in males.

Conclusion:

BMI was significantly and directly associated with resting BP in both sexes. Smoking prevalence and PA status were not associated with BP in this sample of Greek young adults.

Smoking effect on ischemic heart disease in young patients

Objective:

To evaluate the effect of tobacco smoking on the risk of nonfatal acute myocardial infarction in young adults (≤45 years).

Patient and Methods:

We conducted a population-based case-control study with 329 incident acute myocardial infarction cases (42 women; 287 men), consecutively admitted to the Cardiology department of hospitals in Aleppo, Syria, and 778 controls (486 women; 292 men), selected within the noninstitutionalized Aleppo population, during 2008-2010. Odds ratios (OR) and 95% confidence intervals (95%CI) were calculated using unconditional logistic regression.

Results:

The prevalence of current smoking was 80.8% in male cases and 53.8% in male controls (OR = 3.63, 95%CI: 2.50, 5.27) and 59.5% of female cases were smokers compared with 35.8% of controls (OR = 2.64, 95%CI: 1.39, 5.02). No interaction was found between current smoking and gender on myocardial infarction risk (P = 0.401). A dose-effect response was present, the odds favoring myocardial infarction reaching an eight-fold increase for those who smoked >25 cigarettes/day compared with never smokers. The risk estimate for former smokers was similar to never smokers.

Conclusions:

Tobacco smoking is an important independent risk factor for acute myocardial infarction in young adults, with similar strength of association for both genders.

Gender differences in the association between smoking and dyslipidemia: 2005 Korean National Health and Nutrition Examination Survey

BACKGROUND

Smoking has been reported to be associated with abnormal lipid metabolism. However, it remains uncertain whether adverse metabolic effects of smoking on dyslipidemia differ with gender. The objective of this study was to investigate the association between smoking and dyslipidemia in men and women.

METHODS

We analyzed data from 2166 men and 3003 women aged ≥20 years assessed in the Third Korea National Health and Nutrition Examination Survey (2005). Dyslipidemia was defined according to the National Cholesterol Education Program-Adult Treatment Panel III.

RESULTS

The prevalence of dyslipidemia was higher in men than in women. The odds ratios (95% confidence interval) of dyslipidemia associated with current smoking were 1.35 (0.98-1.85) in men and 1.92 (1.19-3.10) in women (p for interaction with gender <0.001). After stratification by components of dyslipidemia, women smokers showed higher odds ratios of having high triglyceride and low high-density lipoprotein cholesterol than men smokers. The association between current heavy-smoking (≥20 pack-years) and dyslipidemia was stronger in women than in men.

CONCLUSIONS

The association between smoking and dyslipidemia was significantly different between men and women. Women smokers might be more susceptible to develop dyslipidemia than men smokers.

Gender heterogeneity in the association between lifestyles and non-fatal acute myocardial infarction

Objective

To evaluate the modification effect of sex in the association between lifestyles and acute myocardial infarction (AMI).

Design

Population-based case–control study. Trained interviewers collected information using a standard structured questionnaire. Associations were estimated using unconditional logistic regression. The effect modification by sex was evaluated in the regression models, testing interaction terms between lifestyles and sex.

Setting

Porto, Portugal.

Subjects

Portuguese Caucasian adults, aged ≥18 years. Cases were patients consecutively admitted with an incident AMI during 1999–2003 (n 918) and controls were a representative sample of non-institutionalized inhabitants of Porto with no evidence of previous clinical or silent infarction (n 2316).

Results

Cigarette smoking was positively associated with AMI in both men and women (smokers >15 cigarettes/d v. never smokers: OR = 9·11, 95 % CI 4·83, 17·20 for women; OR = 3·92, 95 % CI 2·75, 5·58 for men; interaction term P value = 0·001). A significant protective effect of moderate alcohol intake on AMI occurrence was found in women (0·1–15·0 g/d v. non-drinkers: OR = 0·48, 95 % CI 0·31, 0·74), but not in men. Fruit and vegetable intake, vitamin and mineral supplement use and leisure-time physical activity practice were found to decrease AMI risk, with similar effects between sexes.

Conclusions

A strong positive association between smoking and AMI was found in women. Also, a protective effect of moderate alcohol intake was only found among females. Fruit and vegetable intake, vitamin and mineral supplement use and leisure-time physical activity practice were found to decrease AMI risk in both sexes.

Androgens and erythropoiesis: past and present

Association between androgens and erythropoiesis has been known for more than seven decades. Androgens stimulate hematopoietic system by various mechanisms. These include stimulation of erythropoietin release, increasing bone marrow activity and iron incorporation into the red cells. Before the discovery of recombinant erythropoietin (rhEpo), androgens were used in the treatment of anemia associated with renal disease, bone marrow suppression, and hypopituitarism. Anabolism is an additional advantage of androgen therapy. Furthermore, in light of recent reports regarding adverse effects of rhEpo, the role of androgen therapy in various types of anemias should be readdressed. Polycythemia remains a known side effect of androgen therapy. In this review, we will briefly discuss the initial animal and human studies which demonstrated the role of androgens in the treatment of anemia, their mechanism of action, a detailed account of the efficacy of androgens in the treatment of various anemias, the erythropoietic side effects of androgens and finally, the relationship between hematocrit levels and cardiovascular disease.

Determinants of continuity and change over 10 years in young women's smoking

AIMS

To examine prospectively continuity and change in smoking behaviour and associated attributes over a 10-year period.

DESIGN, SETTING AND PARTICIPANTS

Participants (initially aged 18-23 years) in the Australian Longitudinal Study on Women's Health completed postal questionnaires in 1996, 2000, 2003 and 2006. The analysis sample was 6840 women who participated in all surveys and provided complete smoking data.

MEASUREMENTS

Outcome variables were transitions in smoking behaviour between surveys 1 and 2, 2 and 3, 3 and 4 and 1 and 4. Attributes that differentiated continuing smokers from quitters, relapsers from ex-smokers and adopters from never smokers were examined for each survey period. Explanatory variables included previous smoking history, demographic, psychosocial, life-style risk behaviour and life-stage transition factors.

FINDINGS

Over 10 years, 23% of participants either quit, re-started, adopted or experimented with smoking. Recent illicit drug use and risky or high-risk drinking predicted continued smoking, relapse and smoking adoption. Marriage or being in a committed relationship was associated significantly with quitting, remaining an ex-smoker and not adopting smoking. Living in a rural or remote area and lower educational attainment were associated with continued smoking; moderate and high physical activity levels were associated positively with remaining an ex-smoker.

CONCLUSIONS

Life-style and life-stage factors are significant determinants of young women's smoking behaviour. Future research needs to examine the inter-relationships between tobacco, alcohol and illicit drug use, and to identify the determinants of continued smoking among women living in rural and remote areas. Cessation strategies could examine the role of physical activity in relapse prevention.

Cigarette smoking and acne in adolescents: results from a cross-sectional study

BACKGROUND

Previous studies on the association between smoking and acne have reported conflicting results.

OBJECTIVE

To investigate the association between smoking and acne among school-going adolescents.

METHODS

A cross-sectional study was conducted. Smoking was defined as smoking > 3 cigarettes daily for 6 months or more. We defined acne as having > 20 retentional and/or inflammatory facial acne lesions. Multivariate (proportional) logistic regression models were used to adjust for confounding variables.

RESULTS

Of the 594 participants, 36.2% had acne. Acne sufferers were less likely to smoke (18.1 vs. 23.7%, P = 0.10). In girls, smoking was significantly associated with lower prevalence of acne (adjusted OR = 0.41, 95% CI = 0.13, 0.82). Smoking, daily cigarette consumption and duration of smoking appeared to be protective in the development of inflammatory acne in girls. No significant associations between acne and smoking variables were detected among boys.

LIMITATIONS

although this study suggests a significant negative association between smoking and inflammatory acne in girls, it does not prove causality. This association did show a trend for linear relationship. Because of the unexpected differences between boys and girls, sample size may have affected our results.

CONCLUSION

The anti-inflammatory effects of smoking may inhibit the development of papulopustular acne in girls more than in boys. However, smoking should not be considered a therapeutic option for acne. Additional studies that consider possible differences across age, gender and type of acne are needed to clarify the association between smoking and acne.

Tobacco smoking and acute myocardial infarction in young adults: a population-based case-control study

OBJECTIVE

To evaluate the effect of tobacco smoking on the risk of non-fatal acute myocardial infarction in young adults (< or = 45 years), and whether there is modification of this effect by sex.

METHODS

We conducted a population-based case-control study with 329 incident acute myocardial infarction cases (42 women; 287 men), consecutively admitted to the Cardiology department of hospitals in Porto, Portugal, and 778 controls (486 women; 292 men), selected within the non-institutionalized Porto population, during 2001-2003. Odds ratios and 95% confidence intervals (OR, 95%CI) were calculated using unconditional logistic regression.

RESULTS

The prevalence of current smoking was 80.8% in male cases and 53.8% in male controls (OR=3.63, 95%CI: 2.50, 5.27) and 59.5% of female cases were smokers compared to 35.8% of controls (OR=2.64, 95%CI: 1.39, 5.02). No interaction was found between current smoking and sex on myocardial infarction risk (p=0.401). A dose-effect response was present, the odds favoring myocardial infarction reaching an eight-fold increase for those that smoked > 25 cigarettes/day compared to never smokers. The risk estimate for former smokers was similar to never smokers.

CONCLUSIONS

Tobacco smoking is an important independent risk factor for acute myocardial infarction in young adults, with similar strength of association for both sexes.

Polymorphic light eruption may be associated with cigarette smoking and alcohol consumption

BACKGROUND

Although the genetic influence on polymorphic light eruption (PLE) is well established, the role of lifestyle factors is less well defined.

METHODS

A retrospective case-control study was conducted that included 74 PLE patients and 102 controls. Each participant was interviewed about demographic, disease and lifestyle characteristics such as smoking, alcohol consumption and use of medications. Multivariate logistic regression models were used to calculate adjusted odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Compared with the controls, patients with PLE were significantly more likely to be younger females (P<0.05). Univariate analysis did not show a significant association between any of the smoking-related questions and PLE. However, after adjusting for gender and drinking alcohol, patients with PLE were significantly more likely to smoke 15 cigarettes or more daily [adjusted OR=4.06 (95% CI=1.19, 13.80) compared with 0 daily cigarettes] than controls. Participants who consumed six or more drinks a week were less likely to have PLE [adjusted OR=0.24 (95% CI=0.07, 0.80)]. In contrast, women who used oral anticonceptives for a longer period were four-fold more likely to have PLE [adjusted OR=4.74 (95% CI=1.33, 16.86)].

CONCLUSION

Several lifestyle factors may be associated with PLE, but further studies are warranted to confirm these retrospective findings.

Epidemiology of substance use disorders in women

Significant gender differences exist in the prevalence of substance use disorders in the United States. There is a trend among boys and girls aged 12 to 17 years toward comparable rates of use and initiation for alcohol, cocaine, heroin, and tobacco. If this trend continues, over time there may be a narrowing of the male-to-female prevalence ratios of substance abuse in the older age groups. This possibility is particularly disturbing because women have a heightened vulnerability to medical, physical, mental, and social consequences of substance use. Women also carry additional unique risks during pregnancy because of the effect on neonates. In addition, they have certain gender-specific cancer risks. Given this and the declining age of initiation of substance use in women, prevention and treatment efforts especially geared toward women (eg, education of all medical and paramedical staff, screening in primary care clinics, detection of drug use early in pregnancy or before conception, brief interventions and treatment programs that integrate women's needs) are exceedingly important to stop and ultimately reverse this growing trend.

[Calculation of coronary risk in the 35-60 year old population registered at a health centre]

OBJECTIVES

To stratify the population between 35 and 60 years old according to their coronary risk (CR) and to identify the modifiable cardiovascular risk factors that affect our population.

DESIGN

Transversal, descriptive study.

SETTING

Cabañaquinta Health Centre, in a rural health district in Asturias area VII.Participants. Simple randomised sampling based on the health cards of the population between 35 and 60 years old assigned to a health centre. Total number of people included was 205, and 95 did not reply.

MAIN MEASUREMENTS

The variables were: age, sex, total cholesterol, HDL-cholesterol, triglycerides, diastolic blood pressure, systolic blood pressure, tobacco dependency, diabetes, hypertension treatment, treatment for lipaemia, and personal background of cardiovascular disease (CVD). CR was calculated with the ATP-III tables (Adult Treatment Panel III). High CR was understood as over 20% likelihood of developing CVD or having recurrent episodes of CVD in the next 10 years.

RESULTS

A simple descriptive study was conducted. 53% were women; mean age was 48. 37% were smokers, 27% with lipaemia and 29% with hypertension. Mean systolic pressure was 126 mm Hg, mean diastolic pressure was 80 mm Hg. Cholesterol was 213 mg/dL (confidence interval [CI], 174-252), HDL-cholesterol 52.64 mg/dL (CI, 39.94-65.34), LDL-cholesterol 139 mg/dL (CI, 104-174) and triglycerides 106.02 mg/dL (CI, 19.72-192.32). 45% of the sample had two or more CV risk factors. Mean CV risk in the population was 5.3% (CI, <1%-11.3%). According to the table used, 2% of the population had high CR.

CONCLUSIONS

Most of our population had moderate risk. The most common group of patients is a young woman smoker with moderate risk. Tobacco is the most prevalent modifiable risk factor.

Reduction of primary and secondary smoke exposure for low-income black pregnant women

Cigarette smoking by women during pregnancy continues to be a substantial contributor to poor perinatal outcomes in the United States. Decreasing tobacco smoke exposure for women and children is a lifestyle change that will improve perinatal health. A study was conducted with a sample of 74 low-income black women to evaluate the effectiveness of the Smoke Free Families intervention in moving pregnant women forward in the stages of change toward becoming a non-smoker and reducing exposure to second-hand smoke. Transtheoretical model variables were measured at intake, postintervention, and during the last month of pregnancy. There were no statistically significant differences between treatment and control group in movement forward in the stages of change. The findings raise questions about the conceptual fit of the transtheoretical model with pregnant women. We discuss additional interventions and suggest types of studies that would provide new insight into tobacco exposure issues for pregnant women.

Hematocrit and the risk of coronary heart disease mortality

BACKGROUND

An association between hematocrit (Hct) and coronary heart disease (CHD) mortality has been previously observed. However, the relationship of Hct and CHD independent of other cardiovascular disease (CVD) risk factors and differences between men and women remain unclear.

METHODS

We examined the association between Hct and CHD mortality with Cox regression analyses of data from 8896 adults, aged 30-75 years, in the Second National Health and Nutrition Examination Survey (NHANES II) Mortality Study (1976-1992). Covariates included age, sex, race, education, smoking status, hypertensive status, total serum cholesterol, body mass index, white blood cell count, and history of CVD and diabetes. Hct was categorized by use of sex-specific tertiles, and all analyses were stratified by sex.

RESULTS

During 16.8 years of follow-up, there were 545 (men 343, women 202) deaths from CHD (International Classification of Diseases, 9th revision [ICD-9] 410-414), 778 (men 426, women 279) deaths from diseases of the heart (ICD-9 390-398, 402, 404, 410-414, 415-417, 420-429), and 2046 (men 1216, women 830) all-cause deaths. Among men, the crude CHD mortality rate per 10,000 population was 42.6, 31.9, and 46.3 among those with Hct in the lower, middle, and upper tertiles, respectively. The corresponding crude CHD mortality rates among women were 12.6, 18.6, and 27.7. After adjustment for age and other CVD risk factors, there was no association between Hct in the upper tertile compared with the lower tertile and mortality from either CHD, diseases of the heart, or all causes among men. Women with Hct in the upper tertile were 1.3 times (95% CI 0.9-1.9) more likely to die from CHD than were women with Hct in the lowest tertile, after multivariate adjustment. The effect of high Hct on CHD mortality among women younger than 65 years of age was slightly stronger (relative risk 2.2, 95% CI 1.0-4.6).

CONCLUSIONS

These results suggest that the association between Hct and mortality from CHD and all causes is complex, differing both by sex and age. Further research is needed to gain a better understanding of these age and sex differences.

Smoke alarm: a review of the clinical impact of smoking on women

This article is a review of the health impacts of smoking on women and their newborns, with an overview of the prevalence of smoking, mortality statistics, and costs. Over 50 disorders related to smoking are identified. These include many chronic and severe problems that are often overshadowed by the more well-known impacts of cancer and cardiac disease. Female impacts of smoking include two-fold rates of ectopic pregnancy, premature delivery, and low-birthweight infants; earlier menopause; pelvic-floor disorders, including urinary incontinence; menstrual disturbances; decreased fertility; greater risk of oral contraceptive failure; and babies with increased rates of sudden infant death syndrome, asthma, and attention-deficit disorders. From a clinical perspective, one in five women is addicted to nicotine. In addition, women smokers experience a stronger response to nicotine and incur higher rates of lung cancer and cardiovascular disease than their male counterparts.

Cigarette smoking, endothelial injury and cardiovascular disease

Despite the fact that the epidemiological evidence linking cigarette smoking with cardiovascular disease is overwhelming, the precise components of cigarette smoke responsible for this relationship and the mechanisms by which they exert their effect have not yet been elucidated. There are however, some promising pointers as a result of recent developments and this review concentrates on new evidence since earlier reviews of this topic. It is now known that the endothelium has a vastly more important role than was ever thought to be the case a decade ago. Its role in health and disease is increasingly understood, as is the relationship between endothelial injury and the development of atherosclerosis. There is considerable evidence that cigarette smoking can result in both morphological and biochemical disturbances to the endothelium both in vivo and in cell culture systems. Cigarette smoke is a complex mixture and only a few components have been extensively studied. Nicotine and carbon monoxide are much less damaging than is whole smoke. However the free radical components of cigarette smoke have been shown to cause damage in model systems. Further work will be necessary to consolidate the evidence base but the data reported in this review suggest that the free radical components of cigarette smoke may be responsible for the morphological and functional damage to endothelium that has been observed in model systems.

Current smokers develop more posterior myocardial infarctions probably due to increased tendency to thrombosis

This investigation was carried out to determine whether smokers developed smaller infarcts as assessed by peak enzyme levels and also to what extent smoking could modify infarct localization. The study included 753 patients, of whom 351 had no history of previous coronary heart disease (CHD) (angina pectoris and/or myocardial infarction (MI)). The investigation was designed as an exposed (smoking) versus non-exposed (non-smoking) cohort study. Outcome was infarct size, posterior versus non-posterior MI and non-Q-wave versus Q-wave infarcts. In the total cohort of patients, 312 (41%) were smokers, the corresponding number in the restricted cohort of patients without a previous CHD (CHD-0-pts) was 169 (48%). Smokers were younger than non-smokers, and more of them were males. It was found that infarct size was similar in smokers and in non-smokers (crude and adjusted effects). Crude effects showed that smokers developed significantly more posterior infarcts than non-smokers; odds ratio (OR) for developing a posterior MI was 1.95 (2p < 0.001) (all patients) and 2.34 (2P < 0.001) (CHD-0-pts), respectively. After adjusting for confounders (logistic regression model), OR in the two groups was 1.24 (2p = 0.256) and 1.95 (2p = 0.01), respectively. The study shows that current smokers were younger, and indicates that in those without a previous CHD, significantly more of them developed a posterior MI.

Hypertension and pregnancy-related hypertension

Pregnant women with hypertension can be divided into two groups: normotensive women who develop the uniquely pregnancy-related syndrome of preeclampsia, which is characterized by hypertension, proteinuria, and edema; and women with chronic hypertension who become pregnant and are at increased risk for developing superimposed preeclampsia. Preeclampsia is a syndrome of generalized endothelial dysfunction initiated by abnormal placentation and consequent placental under-perfusion, release of cytokines and other toxins, and vasoconstriction and platelet activation. Preeclampsia is the major cause of both maternal and fetal morbidity and mortality and may be complicated by eclampsia (seizures) and hepatic and renal failure. The process is completely reversible by delivery of the fetus and placenta, but intrauterine growth retardation and premature delivery pose major threats to the fetus and may require care in tertiary care center. Treatment of preexisting or pregnancy-induced hypertension does not prevent or reverse the process, but is justified to prevent maternal cardiovascular complications, especially during labor and delivery.