The role of risk factors in heart attacks occurring in men with pre-existing ischaemic heart disease

Physical Stress Echocardiography: Prediction of Mortality and Cardiac Events in Patients with Exercise Test showing Ischemia

Background

Studies have demonstrated the diagnostic accuracy and prognostic value of physical stress echocardiography in coronary artery disease. However, the prediction of mortality and major cardiac events in patients with exercise test positive for myocardial ischemia is limited.

Objective

To evaluate the effectiveness of physical stress echocardiography in the prediction of mortality and major cardiac events in patients with exercise test positive for myocardial ischemia.

Methods

This is a retrospective cohort in which 866 consecutive patients with exercise test positive for myocardial ischemia, and who underwent physical stress echocardiography were studied. Patients were divided into two groups: with physical stress echocardiography negative (G1) or positive (G2) for myocardial ischemia. The endpoints analyzed were all‑cause mortality and major cardiac events, defined as cardiac death and non-fatal acute myocardial infarction.

Results

G2 comprised 205 patients (23.7%). During the mean 85.6 ± 15.0-month follow-up, there were 26 deaths, of which six were cardiac deaths, and 25 non-fatal myocardial infarction cases. The independent predictors of mortality were: age, diabetes mellitus, and positive physical stress echocardiography (hazard ratio: 2.69; 95% confidence interval: 1.20 – 6.01; p = 0.016). The independent predictors of major cardiac events were: age, previous coronary artery disease, positive physical stress echocardiography (hazard ratio: 2.75; 95% confidence interval: 1.15 – 6.53; p = 0.022) and absence of a 10% increase in ejection fraction. All-cause mortality and the incidence of major cardiac events were significantly higher in G2 (p < 0. 001 and p = 0.001, respectively).

Conclusion

Physical stress echocardiography provides additional prognostic information in patients with exercise test positive for myocardial ischemia.

Hypertension and acute myocardial infarction: an overview

History of hypertension is a frequent finding in patients with acute myocardial infarction (AMI) and its recurring association with female sex, diabetes, older age, less frequent smoking and more frequent vascular comorbidities composes a risk profile quite distinctive from the normotensive ischemic counterpart.Antecedent hypertension associates with higher rates of death and morbid events both during the early and long-term course of AMI, particularly if complicated by left ventricular dysfunction and/or congestive heart failure. Renin-angiotensin-aldosterone system blockade, through either angiotensin-converting enzyme inhibition, angiotensin II receptor blockade or aldosterone antagonism, exerts particular benefits in that high-risk hypertensive subgroup.In contrast to the negative implications carried by antecedent hypertension, higher systolic pressure at the onset of chest pain associates with lower mortality within 1 year from coronary occlusion, whereas increased blood pressure recorded after hemodynamic stabilization from the acute ischemic event bears inconsistent relationships with recurring coronary events in the long-term follow-up.Whether antihypertensive treatment in post-AMI hypertensive patients prevents ischemic relapses is uncertain. As a matter of fact, excessive diastolic pressure drops may jeopardize coronary perfusion and predispose to new acute coronary events, although the precise cause-effect mechanisms underlying this phenomenon need further evaluation.

WITHDRAWN: Smoking cessation for the secondary prevention of coronary heart disease

BACKGROUND

Although the importance of smoking as a risk factor for coronary heart disease is beyond doubt, the speed and magnitude of risk reduction when a smoker with coronary heart disease quits are still subjects of debate.

OBJECTIVES

To estimate the magnitude of risk reduction when a patient with CHD stops smoking.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL) , MEDLINE, EMBASE, Science Citation Index, CINAHL, PsychLit, Dissertation Abstracts, BIDS ISI Index to Scientific and Technical Proceedings, UK National Research Register from the start of each database. Sixty-one large international cohort studies of cardiovascular disease were identified, and contact made with authors to search for any unpublished results. The search was supplemented by cross-checking references and contact with various experts. Date of last search was April 2003.

SELECTION CRITERIA

Any prospective cohort studies of patients with a diagnosis of CHD, which include all-cause mortality as an outcome measure. Smoking status must be measured on at least two occasions to ascertain which smokers have quit, and followed-up for at least two years.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed independently by two reviewers.

MAIN RESULTS

Twenty studies were included. There was a 36% reduction in crude relative risk (RR) of mortality for those who quit smoking compared with those who continued to smoke (RR 0.64, 95% confidence interval (CI) 0.58 to 0.71). There was also a reduction in non-fatal myocardial infarctions (crude RR 0.68, 95% CI 0.57 to 0.82). Many studies did not adequately address quality issues, such as control of confounding, and misclassification of smoking status. However, there was little difference in the results for the six 'higher quality' studies, and little heterogeneity between these studies. This review was not able to assess how quickly the risk of mortality was reduced.

AUTHORS' CONCLUSIONS

Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD. The pooled crude RR was 0.64 (95% CI 0.58 to 0.71). This 36% risk reduction appears substantial compared with other secondary preventive therapies such as cholesterol lowering which have received greater attention in recent years. The risk reduction associated with quitting smoking seems consistent regardless of differences between the studies in terms of index cardiac events, age, sex, country, and time period. However, relatively few studies have included large numbers of older people, women, or people of non-European descent, and most were carried out in Western countries.

Serum albumin and risk of stroke, coronary heart disease, and mortality: the role of cigarette smoking

OBJECTIVE

Lower levels of serum albumin are associated with increased risk of all-cause and cardiovascular mortality as well as with coronary heart disease and stroke incidence. These relationships have been examined with specific focus on the role of cigarette smoking.

STUDY DESIGN AND SETTING

A prospective study of 7,690 British men aged 40-59 years, with 16.8 years mean follow-up.

RESULTS

Cigarette smoking was strongly and inversely associated with serum albumin concentrations that reverted to levels seen in never smokers after 5 years' cessation. Only in current and former smokers were there significant inverse relationships between serum albumin and risk of major CHD and stroke events even after adjustment for potential confounders. Only in current smokers was a significant inverse relationship seen between serum albumin and mortality from cardiovascular disease, cancer, and all causes.

CONCLUSION

The inverse association between serum albumin concentration and disease outcome appears to be related to the effects of cigarette smoking on serum albumin concentration.

Smoking cessation for the secondary prevention of coronary heart disease

BACKGROUND

Although the importance of smoking as a risk factor for coronary heart disease is beyond doubt, the speed and magnitude of risk reduction when a smoker with coronary heart disease quits are still subjects of debate.

OBJECTIVES

To estimate the magnitude of risk reduction when a patient with CHD stops smoking.

SEARCH STRATEGY

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index, CINAHL, PsychLit, Dissertation Abstracts, BIDS ISI Index to Scientific and Technical Proceedings, UK National Research Register from the start of each database. Sixty-one large international cohort studies of cardiovascular disease were identified, and contact made with authors to search for any unpublished results. The search was supplemented by cross-checking references and contact with various experts. Date of last search was April 2003.

SELECTION CRITERIA

Any prospective cohort studies of patients with a diagnosis of CHD, which include all-cause mortality as an outcome measure. Smoking status must be measured on at least two occasions to ascertain which smokers have quit, and followed-up for at least two years.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed independently by two reviewers.

MAIN RESULTS

Twenty studies were included. There was a 36% reduction in crude relative risk (RR) of mortality for those who quit smoking compared with those who continued to smoke (RR 0.64, 95% confidence interval 0.58 to 0.71). There was also a reduction in non-fatal myocardial infarctions (crude RR 0.68, 95% confidence interval 0.57 to 0.82). Many studies did not adequately address quality issues, such as control of confounding, and misclassification of smoking status. However, there was little difference in the results for the six 'higher quality' studies, and little heterogeneity between these studies. This review was not able to assess how quickly the risk of mortality was reduced.

REVIEWER'S CONCLUSIONS

Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD. The pooled crude RR was 0.64 (95% CI 0.58 to 0.71). This 36% risk reduction appears substantial compared with other secondary preventive therapies such as cholesterol lowering which have received greater attention in recent years. The risk reduction associated with quitting smoking seems consistent regardless of differences between the studies in terms of index cardiac events, age, sex, country, and time period. However, relatively few studies have included large numbers of older people, women, or people of non-European descent, and most were carried out in Western countries.

Hospital- and clinic-based smoking cessation interventions for smokers with cardiovascular disease

Cigarette smoking is the leading preventable cause of death in the United States and a major risk factor for cardiovascular disease (CVD). Large observational epidemiologic studies conducted in diverse populations have demonstrated a strong association between smoking and CVD morbidity and mortality. Observational epidemiologic studies have also demonstrated a substantial benefit of smoking cessation on cardiovascular morbidity and mortality. Smoking cessation after myocardial infarction reduces subsequent cardiovascular mortality by nearly 50%. Therefore, the use of effective strategies to reduce the prevalence of tobacco use is a high priority for both the primary and secondary prevention of CVD. Effective smoking cessation interventions have been identified in randomized controlled trials in the general population of smokers. These methods, which include behavioral counseling and pharmacotherapy, are incorporated into clinical practice guidelines for physicians in the United States and Great Britain. A smaller but still substantial body of evidence demonstrates the efficacy of these interventions in hospital- and clinic-based settings for smokers with CVD. This evidence is sufficient to support the routine implementation of these smoking cessation methods in inpatient and outpatient settings for smokers with CVD.

Smoking cessation for the secondary prevention of coronary heart disease

BACKGROUND

Although the importance of smoking as a risk factor for coronary heart disease is beyond doubt, the speed and magnitude of risk reduction when a smoker with coronary heart disease quits are still subjects of debate.

OBJECTIVES

To estimate the magnitude of risk reduction when a patient with CHD stops smoking.

SEARCH STRATEGY

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index, CINAHL, PsychLit, Dissertation Abstracts, BIDS ISI Index to Scientific and Technical Proceedings, UK National Research Register from the start of each database. Sixty-one large international cohort studies of cardiovascular disease were identified, and contact made with authors to search for any unpublished results. The search was supplemented by cross-checking references and contact with various experts. Date of last search was April 2003.

SELECTION CRITERIA

Any prospective cohort studies of patients with a diagnosis of CHD, which include all-cause mortality as an outcome measure. Smoking status must be measured on at least two occasions to ascertain which smokers have quit, and followed-up for at least two years.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed independently by two reviewers.

MAIN RESULTS

Twenty studies were included. There was a 36% reduction in crude relative risk (RR) of mortality for those who quit smoking compared with those who continued to smoke (RR 0.64, 95% confidence interval 0.58 to 0.71). There was also a reduction in non-fatal myocardial infarctions (crude RR 0.68, 95% confidence interval 0.57 to 0.82). Many studies did not adequately address quality issues, such as control of confounding, and misclassification of smoking status. However, there was little difference in the results for the six 'higher quality' studies, and little heterogeneity between these studies. This review was not able to assess how quickly the risk of mortality was reduced.

REVIEWER'S CONCLUSIONS

Quitting smoking is associated with a substantial reduction in risk of all-cause mortality among patients with CHD. The pooled crude RR was 0.64 (95% CI 0.58 to 0.71). This 36% risk reduction appears substantial compared with other secondary preventive therapies such as cholesterol lowering which have received greater attention in recent years. The risk reduction associated with quitting smoking seems consistent regardless of differences between the studies in terms of index cardiac events, age, sex, country, and time period. However, relatively few studies have included large numbers of older people, women, or people of non-European descent, and most were carried out in Western countries.

Serum total homocysteine and coronary heart disease: prospective study in middle aged men

OBJECTIVES

To examine the prospective relation between total homocysteine and major coronary heart disease events.

DESIGN

A nested case-control study carried out within the British regional heart study, a prospective investigation of cardiovascular disease in men aged 40-59 years at entry. Serum total homocysteine concentrations were analysed retrospectively and blindly in baseline samples from 386 cases who had a myocardial infarct during 12.8 years of follow up and from 454 controls, frequency matched by age and town.

RESULTS

Geometric mean serum total homocysteine was slightly higher in cases (14.2 micromol/l) than in controls (13.5 micromol/l), a proportional difference of 5.5% (95% confidence interval (CI) -0.02% to 10.8%, p = 0.06). Age adjusted risk of myocardial infarction increased weakly with log total homocysteine concentration; a 1 SD increase in log total homocysteine (equivalent to a 47% increase in total homo cysteine) was associated with an increase in odds of myocardial infarction of 1.15 (95% CI 1.00 to 1. 32; p = 0.05). The relation was particularly marked in the top fifth of the total homocysteine distribution (values >16.5 micromol/l), which had an odds ratio of 1.77 (95% CI 1.28 to 2.42) compared with lower levels. Adjustment for other risk factors had little effect on these findings. Total homocysteine concentrations more than 16.5 micromol/l accounted for 13% of the attributable risk of myocardial infarction in this study population. Serum total homocysteine among control subjects varied between towns and was correlated with town standardised mortality ratios for coronary heart disease (r = 0.43, p = 0.08).

CONCLUSIONS

Serum total homocysteine is prospectively related to increased coronary risk and may also be related to geographical variation in coronary risk within Britain. These results strengthen the case for trials of total homocysteine reduction with folate.

Risk indicators for out-of-hospital cardiac arrest in patients with coronary artery disease

The objective of this study was to identify risk factors for sudden cardiac arrest (SCA) in patients with coronary artery disease (CAD). A retrospective case-control study was performed consisting of a group of unselected patients who had suffered SCA and had a clinical history of CAD, and a group of unselected age- and gender-matched CAD control patients living in the region of Maastricht. Information about previous myocardial infarction (MI), left ventricular ejection fraction (LVEF), hypertension, hypercholesterolemia, diabetes mellitus, smoking, and coffee and alcohol consumption was collected. A logistic regression model was fitted to all mentioned variables including age and genders. Included were 117 SCA cases (84% men, mean age 65 years [+/-7]) and 144 control patients (83% men, mean age 63 years [+/-8]). Previous MI (odds ratio [OR] 4.0, 95% confidence interval [CI] 1.7-9.3), hypertension (OR 2.9, 95% CI 1.5-6.1), heavy coffee consumption (>10 cups per day) (OR 55.7, 95% CI 6.4-483), and a LVEF <40% (OR 11.2, CI 4.4-28.5) were independent risk indicators for SCA in patients with CAD. Alcohol consumption (1-21 glasses per week) seemed to protect patients with CAD from SCA (OR 0.5, 95% CI 0.2-0.98). These observations suggest that changes in lifestyle factors can be of potential importance in protecting patients with CAD from dying suddenly.

Natural history of myocardial infarction and angina pectoris in a general population sample of middle-aged men: a 16-year follow-up of the Primary Prevention Study, Göteborg, Sweden

OBJECTIVES

Although many studies have described prognosis in patients with coronary heart disease (CHD), few have compared outcome in men with clinical evidence of CHD with healthy men from the general population over an extended follow-up. This study aimed to compare long-term prognosis in men with a history of myocardial infarction (MI) and in men with angina pectoris (AP) without MI, with men without clinical signs of CHD.

DESIGN

Longitudinal general population study.

SETTING

City of Göteborg, Sweden.

SUBJECTS

From a general population sample, 195 men who had survived an MI for 0-19 years (median 3 years) and 314 men with AP but no MI (uncomplicated AP) at baseline in 1974-77 were identified and compared with 6591 men without clinical coronary disease. All were aged 51-59 years. Incident non-fatal and fatal cases occurring until the beginning of 1983 were also followed (n = 317).

MAIN OUTCOME MEASURES

Death from CHD, from other causes and from all causes during a follow-up of at least 16 years.

RESULTS

Overall survival was 72% amongst men without coronary disease, 53% amongst men with uncomplicated AP and 34% amongst men with past MI at baseline. In survivors of MI the risk-factor-adjusted relative risk (RR) of coronary death during follow-up was 6.67 (95% confidence interval (CI) 5.29-8.39), of dying from non-cardiovascular causes 1.35 (0.96-1.91), and of dying from any cause 3.20 (2.67-3.83). During the first 4 years after the baseline examination, the adjusted RR of CHD death was 15.96 (10. 29-24.74), and of dying from any cause 5.22 (3.68-7.41). During the last 4 years of follow-up, relative risk was still 5.87 (3.44-10.01) for CHD death and 2.93 (2.05-4.18) for death from any cause. In men with uncomplicated AP, the adjusted relative risk of CHD death during the first 4 years was 4.05 (2.27-7.22) and 3.23 (2.10-4.96) during the last 4-year period. After the first year, the incident MI cases had the same average annual mortality (about 5%) as the prevalent cases.

CONCLUSIONS

In survivors of MI, mortality risk remained high even after an extended follow-up. Men with angina had a better prognosis, but still a compromised survival compared with the general population.

Cigarette smoking in British men and selection for coronary artery bypass surgery

OBJECTIVE

To examine the relation between smoking status, clinical need, and likelihood of coronary artery bypass grafting in middle aged men.

DESIGN

A prospective study of cardiovascular disease in British men aged 40 to 59 years, screened in 1978-80 and followed until December 1991.

SUBJECTS AND SETTING

7735 men drawn from one general practice in each of 24 British towns.

MAIN OUTCOME MEASURE

Coronary artery bypass graft surgery.

RESULTS

Of the 3185 current smokers, 38 (1.03/1000/year) underwent coronary artery bypass surgery compared with 47 of 2715 (1.45/1000/year) ex-smokers, and 19 of 1817 (0.85/1000/year) never-smokers. Ex-smokers had a lower incidence of major ischaemic heart disease during follow up than current smokers. After adjustment for incidence of ischaemic heart disease during follow up, the hazard ratio of coronary artery bypass surgery for ex-smokers compared with smokers was 1.52 (95% confidence interval 0.99 to 2.34). Ex-smokers were more likely at screening to recall a doctor diagnosis of ischaemic heart disease than smokers (7.1% v 5.3%), but among those who recalled a doctor diagnosis, smokers were less likely to undergo coronary artery bypass surgery than ex-smokers (9.4% v 3.5%, P = 0.026). By 1992, men defined as smokers at screening were no less likely than ex-smokers to have been referred to a cardiologist (18.5% v 18.8%), nor to report having undergone coronary angiography less frequently than ex-smokers (12.7% v 11.4%).

CONCLUSION

Even allowing for the strong relation between coronary artery bypass surgery and clinical need, continuing smokers were less likely to undergo coronary artery bypass surgery than ex-smokers. A complex interplay exists between the men's experience of heart disease, the decision to stop smoking, and the willingness of doctors to consider coronary artery bypass surgery.

Cholesterol in patients with coronary heart disease: how low should we go?

CLINICAL PROBLEM

To examine the evidence supporting the recent National Cholesterol Education Program (NCEP) recommendation that low to moderate levels of cholesterol should be aggressively managed in patients with coronary heart disease (CHD).

METHODS

Cohort studies and clinical trials with angiographic or clinical endpoints, that included CHD patients with low to moderate levels of cholesterol, were systematically identified through a MEDLINE search and critically reviewed.

SYNOPSIS

None of the cohort studies show that a moderate level of cholesterol confers significantly increased risk of CHD death, although a pooled relative risk of 1.14 (95% CI 1.08 to 1.4) suggests that there may be a slight excess risk. Of five angiographic trials of CHD patients with moderate levels of cholesterol, two demonstrated no improvement in angiographic endpoints with intensive lipid-lowering therapy and the other three are difficult to interpret since they included other interventions in addition to the cholesterol-lowering regimen. No large clinical trial with clinical endpoints has been reported for CHD patients with low to moderate levels of cholesterol.

RECOMMENDATIONS

The recommendation to treat CHD patients who have low to moderate levels of cholesterol with diet or drugs is not based on convincing evidence of efficacy. This is in clear contrast to the recommendation for CHD patients with high levels of cholesterol, for whom there is definitive clinical trial evidence of benefit from cholesterol-lowering therapy. While we await clinical trial results for CHD patients with low to moderate levels of cholesterol, clinicians and patients must consider the possible disadvantages of therapy in relation to the uncertain benefit.

Asymptomatic hyperglycaemia and major ischaemic heart disease events in Britain

OBJECTIVE

To examine the association between non-fasting serum glucose concentrations and major ischaemic heart disease (IHD) events (fatal and non-fatal myocardial infarction).

DESIGN

A prospective study.

SUBJECTS

A population based sample of 7735 middle aged British men. Known diabetics, men with a glucose concentration > or = 11.1 mmol/l at screening, and hypertensive patients taking regular medication were excluded from the analysis. With exclusions (n = 509) and missing glucose values (n = 49), there were 7177 men available for analysis.

MAIN OUTCOME MEASURES

Major IHD events (fatal and non-fatal myocardial infarction) during 9.5 years follow up on all men.

RESULTS

There were 505 major IHD events, 222 fatal and 283 non-fatal, in the 7177 men studied. There was a non-linear relation between the glucose concentration and the risk (per 1000 men per year) of all major IHD events and fatal IHD events, with the excess risk in the upper quintile of the glucose distribution (> or = 6.1 mmol/l). The unadjusted relative risks (RR) in the upper glucose concentration quintile compared with the first to the fourth quintiles combined were 1.4 (95% CI 1.1, 1.7) for all events and 1.3 (95% CI 1.0, 1.7) for fatal events. Adjustment for age, smoking, occupational status, body mass index, physical activity, systolic blood pressure, total and high density lipoprotein cholesterol, and triglyceride concentrations had a minimal effect on these relative risk estimates. This non-linear relationship between the serum glucose concentration and the risk of a major IHD event was observed in men with no evidence of IHD at screening (n = 5518) but not in men with IHD (n = 1659). In the former group, the RR (adjusted for major coronary risk factors) for all major IHD events in the upper quintile relative to the lower quintiles combined was 1.5 (95% CI 1.2, 2.0) and for fatal IHD events was 1.8 (95% CI 1.1, 2.6).

CONCLUSION

These data suggest that asymptomatic hyperglycaemia is an independent risk factor for major IHD events.

A new method of estimating cost effectiveness of cholesterol reduction therapy for prevention of heart disease

The purpose of this study was to demonstrate a new method of estimating the cost effectiveness of interventions that lower blood cholesterol levels in the prevention of coronary heart disease (CHD) at the community level. The participants in the study were 67 651 men aged 35 to 64 years in the Lower Hunter region of New South Wales, Australia. Census data, risk factor profiles and CHD event rates from community surveillance, plus costs in 1988-1989 Australian dollars, were used as inputs to a computer program that used a logistic equation. The output estimated the CHD events avoided and the cost effectiveness of an intervention that identified and treated men with cholesterol levels greater than 6.5 mmol/L with dietary modification and cholestyramine. The cost of implementation of the intervention was $A50.1 million to prevent 104 CHD events. The cost-effectiveness ratio was $A482 224 per CHD event avoided (SD = $A24 761) and the direct medical costs avoided were approximately $A500 000 over a 5-year period ($A4535.07 per CHD event avoided). Drug acquisition costs contributed substantially (88%) to the total costs of interventions that rely on screening to identify individuals with high cholesterol for intensive treatment.

Ten-year mortality from cardiovascular disease in relation to cholesterol level among men with and without preexisting cardiovascular disease

To determine the associations of total, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) cholesterol with mortality from coronary heart disease and cardiovascular disease, we studied 2541 white men who were 40 to 69 years old at base line and followed them for an average of 10.1 years. Seventeen percent had some manifestation of cardiovascular disease at base line, whereas the others did not. Among the men who had cardiovascular disease at base line, we found, after multivariate adjustment, that those with "high" blood cholesterol levels (above 6.19 mmol per liter) had a risk of death from cardiovascular disease, including coronary heart disease, that was 3.45 times higher (95 percent confidence interval, 1.63 to 7.33) than that for men with "desirable" blood cholesterol levels (below 5.16 mmol per liter). The corresponding hazard ratios were 5.92 (95 percent confidence interval, 2.59 to 13.51) for LDL cholesterol levels above 4.13 mmol per liter as compared with those below 3.35 mmol per liter, and 6.02 (95 percent confidence interval, 2.73 to 13.28) for HDL cholesterol levels below 0.90 mmol per liter as compared with those above 1.16 mmol per liter. All three lipid levels were also significant predictors of death from coronary heart disease alone (P less than 0.005). Total cholesterol and LDL cholesterol levels were also significant predictors of death from cardiovascular and coronary heart disease in men without preexisting cardiovascular disease, although at a lower level of absolute risk of death. Thus, the 10-year risk of death from cardiovascular disease for a man with preexisting cardiovascular disease increased from 3.8 percent to almost 19.6 percent with increasing levels of total cholesterol from "desirable" to "high," whereas the corresponding risk for a man who was free of cardiovascular disease at base line increased from 1.7 percent to 4.9 percent. Our findings suggest that total, LDL, and HDL cholesterol levels predict subsequent mortality in men 40 to 69 years of age, especially those with preexisting cardiovascular disease.

Concentrations of high density lipoprotein cholesterol, triglycerides, and total cholesterol in ischaemic heart disease

OBJECTIVE

To assess the roles of serum concentrations of total cholesterol, high density lipoprotein cholesterol, and triglycerides in predicting major ischaemic heart disease.

DESIGN

Men recruited for the British regional heart study followed up for a mean of 7.5 years.

SETTING

General practices in 24 British towns.

PATIENTS

7735 Middle aged men.

END POINT

Predictive value of serum concentrations of lipids.

MEASUREMENTS AND MAIN RESULTS

At initial screening serum concentrations of total cholesterol, high density lipoprotein cholesterol, and triglycerides were determined from non-fasting blood samples. Altogether 443 major ischaemic heart disease events (fatal and non-fatal) occurred during the study. Men in the highest fifth of the distribution of total cholesterol concentration (greater than or equal to 7.2 mmol/l) had 3.5 times the risk of ischaemic heart disease than did men in the lowest fifth (less than 5.5 mmol/l) after adjustment for high density lipoprotein cholesterol concentration and other risk factors. Men in the lowest fifth of high density lipoprotein cholesterol concentration (less than 0.93 mmol/l) had 2.0 times the risk of men in the highest fifth (greater than or equal to 1.33 mmol/l) after adjustment for total cholesterol concentration and other risk factors. Men in the highest fifth of triglyceride concentration (greater than or equal to 2.8 mmol/l) had only 1.3 times the risk of those in the lowest fifth (less than 1.08 mmol/l) after adjustment for total cholesterol concentration and other risk factors; additional adjustment for high density lipoprotein cholesterol concentration made the association with ischaemic heart disease disappear.

CONCLUSIONS

Serum concentration of total cholesterol is the most important single blood lipid risk factor for ischaemic heart disease in men. High density lipoprotein cholesterol concentration is less important, and triglyceride concentrations do not have predictive importance once other risk factors have been taken into account.