Risk of myocardial infarction in young female smokers

U.S. Medical Eligibility Criteria for Contraceptive Use, 2024

The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1-103). Notable updates include 1) the addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and 3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

Acute Myocardial Infarction in a Young Man with Hyperhomocysteinemia and Pulmonary Tuberculosis

Acute myocardial infarction, hyperhomocysteinemia and pulmonary tuberculosis (PTB) are rare in individuals under the age of 30 years. We herein report the case of a 27-year-old man who presented with intermittent chest pain, elevated homosysteine level, and PTB. The patient was treated successfully with a combination of medications and percutaneous coronary intervention. This uncommon case highlights that homocysteine, folate and B vitamins levels should be regularly evaluated, and that chest X-rays or thoracic computed tomography should be ordered routinely to exclude PTB in patients under the age of 30 years who present acute myocardial infarction and lack the traditional risk factors.

Perceptions of personal risk about smoking and health among Bosnian refugees living in the United States

More than 60% of Bosnian refugees in the United States may be current smokers. Examining health beliefs can provide insight into smoking behaviors in this community. Four hundred ninety-nine Bosnians were interviewed about health beliefs and personal health risks related to smoking. ANOVA was used to compare current, former, and never smokers. General health beliefs were significantly different by smoking status with medium effect sizes (P < .001; η(2) = 0.04-0.06); current smokers were less likely to agree that smokers live shorter lives and that smokers are more likely to get heart disease. Significant differences with large effect sizes (P < .001; η(2) = 0.11-0.29) were found in perception of personal risk of lung cancer and heart disease among current, former, and never smokers. Current smokers perceived their own health risks as less severe than those of other smokers. High smoking rates and smokers' optimism related to health indicate that culturally tailored educational and cessation interventions are needed for Bosnian refugee communities.

Smoking reduction at midlife and lifetime mortality risk in men: a prospective cohort study

Previous studies have not shown a survival advantage for smoking reduction. The authors assessed survival and life expectancy according to changes in smoking intensity in a cohort of Israeli working men. Baseline smokers recruited in 1963 were reassessed in 1965 (n = 4,633; mean age, 51 years) and followed up prospectively for mortality through 2005. Smoking intensity at both time points was self-reported and categorized as none, 1-10, 11-20, and ≥21 cigarettes per day. Change between smoking categories was noted, and participants were classified as increased (8%), maintained (65%), reduced (17%), or quit (10%) smoking. During a median follow-up of 26 (quartiles 1-3: 16-35) years, 87% of participants died. Changes in intensity were associated with survival. In multivariable-adjusted models, the hazard ratios for mortality were 1.14 (95% confidence interval (CI): 0.99, 1.32) among increasers, 0.85 (95% CI: 0.77, 0.95) among reducers, and 0.78 (95% CI: 0.69, 0.89) among quitters, compared with maintainers. Inversely, the adjusted odds ratios of surviving to age 80 years were 0.77 (95% CI: 0.60, 0.98), 1.22 (95% CI: 1.01, 1.47), and 1.33 (95% CI: 1.07, 1.66), respectively. The survival benefit associated with smoking reduction was mostly evident among heavy smokers and for cardiovascular disease mortality. These results suggest that decreasing smoking intensity should be considered as a risk-reduction strategy for heavy smokers who cannot quit abruptly.

Women's cardiovascular health: perspectives from South-East Asia

Cardiovascular disease (CVD) is an under-recognized major health problem among women in South-East Asia. The prevalence of cardiovascular risk factors such as hypertension, diabetes mellitus, dyslipidemia, physical inactivity, and being overweight or obese has shown a significantly increasing trend among women in the region, with the exception of Singapore. The problem is compounded by low awareness that CVD is a health problem for women as well as for men, by misconceptions about the disease, and by the lack of suitable, locally available health literature. Efforts have been made by the national heart associations and other organizations to increase heart health awareness and promote healthy lifestyles. Singapore initiated these prevention programs in the early 1990s and has been successful in reducing the prevalence of cardiovascular risk factors. The governments of the region, in accordance with the Noncommunicable Disease Alliance, have begun implementing appropriate preventive strategies and improving health-delivery systems. However, psychological, social, and cultural barriers to cardiovascular health awareness in women need to be addressed before these programs can be fully and successfully implemented.

[Myocardial infarction associated with oral contraceptive use, smoking and elevated cholesterol level in a young patient]

Oral hormonal contraceptives are the safest methods for young patients to avoid unwanted pregnancy. They are well accepted and have certain beneficial effects; however, physicians should pay attention to risk factors even when applied in young age. Obesity, dyslipidemia, smoking and oral contraceptive pills alone or in combination may lead to serious adverse events. Authors present a young woman who developed acute myocardial infarction in association with several unconsidered risk factors including the use of contraceptive pills.

Review of cardiovascular risk factors in women

BACKGROUND

Although cardiovascular disease (CVD) is the leading cause of death in women in the United States, a knowledge gap persists regarding the mechanisms and management of CVD in women. Before treatment can be optimized, the role of cardiovascular risk factors must be elucidated.

OBJECTIVE

This review provides an updated assessment of cardiovascular risk factors in women, with a focus on cardiometabolic risk.

METHODS

MEDLINE and Cochrane Library databases, and statistics from the National Health and Nutrition Examination Survey and the American Heart Association, were searched from 1990 to September 2008 using the following terms: cardiovascular risk factors, women, gender, cardiometabolic risk, abdominal obesity, and metabolic syndrome. Publications were classified as English-only original data, reviews, and clinical guidelines. Nonpublished data were excluded. Data were extracted by 2 reviewers independently.

RESULTS

Investigators performing multivariable predictive models have estimated that traditional risk factors account for approximately 70% of the variance in estimating cardiovascular events. However, substantial sex differences exist in the prevalence of traditional risk factors as well as in cardiovascular outcomes. Hypertension is more prevalent in men until the age of 59 years, but then contributes to greater morbidity in older women. Low levels of high-density lipoprotein and elevated triglyceride levels pose more of a threat to women, yet high levels of low-density lipoprotein pose equal risk for women and men. The CVD mortality rate is -3 times greater in people with diabetes than in those without diabetes. Among diabetic individuals, CVD mortality is slightly higher in women compared with men.

CONCLUSIONS

Increased knowledge of gender-specific risks for CVD has led to national campaigns to educate women. In addition to traditional risk factors, cardiometabolic risk is an important consideration in women. Controversy exists regarding the exact definitions and usefulness of the term metabolic syndrome, but it is clear that the presence of certain factors contributes to increased morbidity and mortality in affected individuals. Abdominal obesity links insulin resistance, dyslipidemia, and hypertension through complex endocrine pathways. Current research is identifying gene x gender interactions, and continued research is necessary to explore the relationship of sex steroids and cardiovascular risk in both men and women.

Lifestyle and Risk of Cardiovascular Disease and Type 2 Diabetes in Women: A Review of the Epidemiologic Evidence

Cardiovascular disease is the leading cause of death among both women and men in the United States, accounting for nearly half of all deaths and considerable morbidity. Type 2 diabetes is a major risk factor for cardiovascular disease and one that is particularly potent in women; its prevalence has increased dramatically in recent years. Epidemiologic data indicate that cardiovascular disease and type 2 diabetes share common risk factors and are largely preventable; indeed, findings from the Nurses' Health Study suggest that 74% of cardiovascular disease cases, 82% of coronary heart disease cases, and 91% of diabetes cases in women could be prevented by not smoking, engaging in regular physical activity, maintaining a healthy weight, eating healthier food, and drinking moderate amounts of alcohol. This article reviews lifestyle risk factors and preventive strategies for cardiovascular disease and type 2 diabetes among women.

Depression and smoking in coronary heart disease

OBJECTIVE

This review examines the relationship between depression and smoking in coronary heart disease (CHD). It summarizes relevant findings from general population and smoking cessation studies and discusses the few studies that have investigated whether smoking confounds, mediates, or moderates the effect of depression on cardiac morbidity and mortality.

METHODS

Qualitative review of research literature.

RESULTS

Although many studies of the prognostic importance of depression in CHD have adjusted for smoking, there is no convincing evidence that smoking actually confounds the relationship between depression and CHD. There is also no evidence that smoking moderates this relationship. There is, however, limited evidence that smoking may partially mediate the effect of depression on morbidity and mortality in CHD.

CONCLUSION

We need more research on the relationship between depression and smoking in CHD to develop a more complete model of the mechanisms linking depression to cardiac morbidity and mortality.

Risk factors for non-fatal acute myocardial infarction in Italian women

BACKGROUND

We analyzed the relation between selected lifestyles and diseases and the risk of non-fatal acute myocardial infarction (AMI) in women in Northern Italy.

METHODS

We used a combined data set from three case-control studies, including 558 cases and 1,044 hospital controls.

RESULTS

The strongest risk factor for AMI was smoking, the odds ratio (OR) being 4.0 in current smokers (11.6 for > or = 5 cigarettes/day). Other risk factors were diabetes (OR 4.4), hypertension (OR 3.3), hyperlipidemia (OR 1.6), and family history of AMI (OR 2.1). Moderate alcohol drinking was protective (OR 0.8 for < 2 drinks/day) compared to non-drinkers, and heavy coffee drinking non-significantly increased the risk (OR 1.4 for >3 cups/day). Inverse association was found with fish (OR 0.7 for >1 portion/week), vegetables (0.7 for > or = 10 portions/week), and fruit (OR 0.6 for > or = 14 portions/week), while meat, whole-grain, and diary products were unrelated. Smoking effect was stronger in combination with diabetes (OR 27.7), hypertension (OR 15.7), hyperlipidemia (OR 6.3), family history of AMI (OR 8.7), and heavy coffee drinking (OR 5.7).

CONCLUSIONS

The strongest risk factor for AMI was smoking, responsible of about 37% of cases, followed by diabetes, hypertension, hyperlipidemia, family history of AMI. Avoidance of smoking and increasing fish, vegetables, and fruit would reduce AMI risk of about 50%.

Measuring perceptions of synergistic circulatory disease risk due to smoking and the oral contraceptive pill

There is evidence that the oral contraceptive pill (OCP) and smoking contribute independently to risk of circulatory disease. There is mixed evidence that the combined risk may be greater than the sum of these factors operating in isolation. Little is known about how the general population views the risks from OCP use, singly and in combination with smoking. Previous attempts at assessing whether the public views risks as operating synergistically have generally found evidence for subadditive models, where the combined risk is less than the sum of factors operating in isolation. However, concerns have been expressed over the validity of the measures of risk perception used. Therefore, this study used three distinct methods of measurement to assess the extent to which 241 undergraduate students perceive the risks of smoking and the OCP separately and combined, for circulatory disease. For all three methods, respondents read each of four vignettes describing information about a woman's risk factors (with high and low levels of both OCP and smoking), and then estimated risk of circulatory disease using one of the three risk measures. The three measures produced similar ratings. Consistent with the epidemiological evidence, information about smoking had more impact on estimates of overall risk than did information about the OCP For all three measures, responses were consistent with an additive model of risk from smoking and the OCP. This convergence of results from different methods suggests that all three methods of measurement employed, which all had a large number of response options, may be valid.

The Role of Cigarette Smoking in the Association Between Periodontal Disease and Coronary Heart Disease

BACKGROUND

Cigarette smoking is a significant risk factor for both coronary heart disease and periodontal disease. The goal of this study was to better understand the role of smoking in the relationship between periodontal disease and heart attack history.

METHODS

The study population consisted of 5,285 participants in the Third National Health and Nutrition Examination Survey (NHANES) during 1988-1994 and who were age 40 years or older when examined. The data analysis employed logistic regression models and accounted for the complex sampling design used in NHANES.

RESULTS

After adjustment for potential confounders, we only found significant associations between periodontal loss of attachment (LOA) and heart attack history for smokers, with odds ratios and 95% confidence interval (CI) of 2.64 (1.48 to 4.71), 3.84 (1.22 to 12.10) and 5.87 (1.91 to 18.00) for those with 2.0 to 2.99, 3.0 to 3.99, and 4 mm or more mean LOA, respectively. When the analysis was stratified by smoking status and tertile of age at heart attack, the statistically significant associations were limited to smokers who had a heart attack between the ages of 25 and 50 years, with odds ratios and 95% Cl associated with increasing mean LOA for this group of 3.29 (1.35 to 8.04), 7.32 (1.60 to 33.51), and 8.04 (1.91 to 18.00), respectively.

CONCLUSIONS

These results suggest that cigarette smoking is a necessary cofactor in the relationship between periodontal disease and coronary heart disease, and the increase in risk appears to be age dependent. However, the key role played by smoking in the etiology of both periodontal and heart diseases makes it difficult to determine how much of the observed association resulted from periodontal disease.

[Baseline characteristics and management of patients less than 45 years of age hospitalized for acute coronary syndromes: results from the nationwide French PREVENIR 1 and PREVENIR 2 studies]

Of 2,626 patients admitted for acute coronary syndromes and participating in the PREVENIR 1 and 2 registries, 202 (8%) were aged less than 45 years. Younger patients were more often smokers (79% versus 37%), but systemic hypertension and diabetes were less frequent. Reperfusion therapy was more frequently used in the younger patients (63% versus 46%). At hospital discharge, aspirin and angiotensin converting enzyme inhibitors were prescribed as often in younger and older patients. In contrast, beta-blocking agents and statins were used more often in the younger patients. More younger patients participated in a cardiac rehabilitation programme. Left ventricular ejection fraction was less altered in the younger age group and none of the younger patients died between hospital discharge and six months follow-up.

The relationship between use of oral contraceptives and myocardial infarction in young women with fatal outcome, compared to those who survive: results from the MICA case-control study

To examine the relationship between use of oral contraceptives and the risk of dying from myocardial infarction, we made a comparison of deceased patients and live patients (women aged less than 45) identified for the Myocardial Infarction Causality case-control study, using data obtained from general practice medical notes. There were 422 live patients and 110 deceased patients of women with a myocardial infarction with data available. The adjusted odds ratio for exposure to second generation oral contraceptives and risk of death within 28 days of a myocardial infarction compared with no oral contraceptive use was raised (2.88, 95% confidence interval 1.22-6.77), and this effect was not seen for other types of oral contraceptives including third generation oral contraceptive formulations. In absolute terms, between 47,000 and 71,000 women would have to be exposed to a second generation pill for one year to result in one extra death from myocardial infarction, and this risk applies mainly to smokers. The results suggest a slightly increased relative risk of death among those having a myocardial infarction associated with exposure to second generation oral contraceptives, but this represents a small absolute risk. Further work is required before any change in contraceptive practice should be advocated.

Occlusive vascular diseases in oral contraceptive users. Epidemiology, pathology and mechanisms

Despite being an unprecedented departure from normal physiology, the combined oral contraceptive is not only highly effective, but it also has a remarkably good safety record. Concerns over safety persist, though, particularly with regard to venous thromboembolism (VTE), stroke and myocardial infarction (MI). Epidemiological studies consistently show an increase in risk of VTE, but the results are more contentious with regard to arterial diseases. Despite 40 years of research, the mechanisms behind these adverse effects are not understood. In this review, we integrate information from published studies of the epidemiology and pathology of the occlusive vascular diseases and their risk factors to identify likely explanations for pathogenesis in oral contraceptive users. Oral contraceptives induce both prothrombotic and fibrinolytic changes in haemostatic factors and an imbalance in haemostasis is likely to be important in oral contraceptive-induced VTE. The complexity of the changes involved and the difficulty of ascribing clinical significance has meant that uncertainty persists. A seriously under-researched area concerns vascular changes in oral contraceptive users. Histologically, endothelial and intimal proliferation have been identified in women exposed to high plasma estrogen concentrations and these lesions are associated with thrombotic occlusion. Other structural changes may result in increased vascular permeability, loss of vascular tone and venous stasis. With regard to arterial disease risk, epidemiological information relating to dose effects and joint effects with other risk factors, and studies of pathology and changes in risk factors, suggests that oral contraceptive use per se does not cause arterial disease. It can, nevertheless, synergise very powerfully with subclinical endothelial damage to promote arterial occlusion. Accordingly, the prothrombotic effects of the oral contraceptive estrogen intervene in a cycle of endothelial damage and repair which would otherwise remain clinically silent or would ultimately progress - in, for example, the presence of cigarette smoking or hypertension - to atherosclerosis. Future work in this area should focus on modification of the effects of established risk factors by oral contraceptive use rather than modification of the supposed risk of oral contraceptive use by established risk factors. Attempts to understand vascular occlusion in oral contraceptive users in terms of the general features of VTE or with reference to atherosclerosis may be limiting, and future work needs to acknowledge that such occlusions may have unique features. Unequivocal identification of the mechanisms involved would contribute considerably to the alleviation of fears over vascular disease and to the development of even safer formulations.