Interfacial vs Bulk Phenomena Effects on the Surface Tensions of Aqueous Magnetic Surfactants in Uniform Magnetic Fields

The literature clearly reports that magnetic surfactant systems respond to magnetic fields. This manuscript investigates if the responses are because the magnetic fields directly alter the interfacial properties or if the surface-active properties are independent of the paramagnetic fluid responses. It uses uniform and gradient magnetic fields to determine the magnetically induced changes to the surface tensions independent of bulk paramagnetic fluid effects for ionic magnetic surfactants. The magnetically induced decrease in surface tensions is small compared to the bulk paramagnetic fluid effects. The reported decrease in surface tensions is significantly smaller than those previously found in the literature, which reported a combined interfacial and bulk paramagnetic effect. The magnetically induced surface tension changes are a function of the degree of association, α, of the magnetic moiety with the surfactant's amphiphilic structure. Therefore, the proposed answer to the question is that as α approaches zero, the magnetic properties of the magnetic surfactant system approaches the behavior of an ordinary paramagnetic fluid. For magnetic surfactants with α approaching one, there is a measurable interfacial response. For example in this study, a magnetic surfactant with α = 0.92 had a 2.5 times greater magnetically induced change in surface tension compared to a magnetic surfactant with α = undetectable, even thought they had similar magnetic moments.

Pharmacology and therapeutic potential of pattern recognition receptors

Pharmacologists have used pathogen-associated molecular patterns (PAMPs), such as lipopolysaccharide (LPS) for decades as a stimulus for studying mediators involved in inflammation and for the screening of anti-inflammatory compounds. However, in the view of immunologists, LPS was too non-specific for studying the mechanisms of immune signalling in infection and inflammation, as no receptors had been identified. This changed in the late 1990s with the discovery of the Toll-like receptors. These 'pattern recognition receptors' (PRRs) were able to recognise highly conserved sequences, the so called pathogen associated molecular patterns (PAMPs) present in or on pathogens. This specificity of particular PAMPs and their newly defined receptors provided a common ground between pharmacologists and immunologists for the study of inflammation. PRRs also recognise endogenous agonists, the so called danger-associated molecular patterns (DAMPs), which can result in sterile inflammation. The signalling pathways and ligands of many PRRs have now been characterised and there is no doubt that this rich vein of research will aid the discovery of new therapeutics for infectious conditions and chronic inflammatory disease.

Factors of caregiver isolation in a rural midwest area

The authors, working with a Veterans Affairs Home Based Primary Care Team in rural areas of Illinois and Indiana, noted the relative social isolation of many family caregivers of patients. They explored several factors that could contribute to this isolation: values held by the caregiver, transportation restraints, limited caregiver resources and caregiver health. Caregiver values, such as obligation and responsibility, stood out, contributing to generally excellent care for the elderly veteran patients, but also to the observed isolation. A solution would be increased funding for in-home respite, to help the family caregivers get needed rest and outings, thus responding to an expressed need, and enhancing their ability to provide "low-tech" in-home care to their loved ones.

Predictors of healthy aging in men with high life expectancies

OBJECTIVE

The purpose of this study was to identify risk factors that consistently predict staying healthy in contrast to developing clinical illness and/or physical and mental impairments.

METHODS

More than 8000 men of Japanese ancestry were followed for 28 years with repeat examinations and surveillance for deaths and incident clinical illness. Physical and cognitive functions were measured in 1993. Measures of healthy aging included surviving and remaining free of major chronic illnesses and physical and cognitive impairments.

RESULTS

Of 6505 healthy men at baseline, 2524 (39%) died prior to the final exam. Of the 3263 available survivors, 41% remained free of major clinical illnesses, 40% remained free of both physical and cognitive impairment, and 19% remained free of both illness and impairment. The most consistent predictors of healthy aging were low blood pressure, low serum glucose, not smoking cigarettes, and not being obese.

CONCLUSIONS

Beyond the biological effects of aging, much of the illness and disability in the elderly is related to risk factors present at midlife.

Can money buy happiness? Depressive symptoms in an affluent older population

OBJECTIVES

To determine if the inverse association between depressive symptoms and income reported in predominantly low- and middle-income older populations is present in a more affluent population of older adults and to determine if this pattern is independent of other known correlates of depressive symptoms such as medical problems, physical disability, and social support.

DESIGN

Cross-sectional analysis within a prospective cohort study.

SETTING

An ongoing, community-based cohort study conducted by an independent research institution in an affluent Northern California county.

PARTICIPANTS

A total of 1948 randomly selected, noninstitutionalized county residents 55 years of age and older who completed the baseline questionnaire and physical performance tests.

MEASUREMENTS

The outcome measure was high level of depressive symptoms (score > or = 16) using the Center for Epidemiologic Studies-Depression scale (CES-D).

RESULTS

The prevalence of high levels of depressive symptoms (CES-D score > or = 16) was lower than in most other population-based samples using an identical CES-D scale. In age-adjusted, sex-specific analyses, increasing income level was associated significantly with lower levels of depressive symptoms, but the nature of the relationship appeared quadratic rather than linear (Men: odds ratio (OR) income .80, 95% confidence interval (CI) .68-.94; income2 OR 1.006, 95% CI 1.001-1.011. Women: OR income .80, 95% CI .69-.91; income2 OR 1.007, 95% CI 1.002-1.011). In multivariate regression analyses including potential confounding risk factors, the magnitude of the association between depressive symptoms and income decreased and was not statistically significant when measures of health conditions, physical disability, and social support were included in the model (Men: OR income .90, 95% CI .75-1.06; income2 OR 1.003, 95% CI .998-1.009. Women: OR income .90, 95% CI .78-1.05; income2 OR 1.003, 95% CI .998-1.008).

CONCLUSION

These findings suggest that poor health, physical disability, and social isolation are the major factors responsible for the observed inverse relationship between income and symptoms of depression in affluent, as well as economically disadvantaged, older populations.

Expanding handgun bullets

BACKGROUND

Many new types of expanding or fragmenting handgun ammunition have been developed. Knowledge of these unusual bullets may aid in the management of patients and their wounds.

METHODS

Eleven different expanding or fragmenting .45 caliber bullets and a nondeforming, full metal jacketed bullet for comparison were fired multiple times from the same handgun into both a water reservoir and ordnance gelatin. Performance was observed and recorded. Muzzle velocities were measured using a chronograph. Bullets were disassembled and cross-sectioned to facilitate inspection.

RESULTS

The distinguishing surface and internal features of each bullet are described. When fired into water and ordnance gelatin, the bullets reliably expanded to 1.49 to 1.89 times their prefired diameters. Rates of kinetic energy loss of bullets of equal mass fired into ordnance gelatin were plotted. Full metal jacketed bullets penetrated twice as deeply as deforming bullets. Jackets of some of the expanding bullets separated when fired into water.

CONCLUSION

Expanding/fragmenting bullets produce larger, shallower wounds than do full metal jacketed bullets. Recognition of the wound and roentgenographic appearances of these unusual bullets will help the trauma surgeon to properly treat gunshot victims. Because of the occurrence of jacket separation in water, ordnance gelatin should be used for optimal evaluation of bullet performance.

Variability in systolic blood pressure--a risk factor for coronary heart disease?

Among 1,433 men of Japanese ancestry living in Hawaii with blood pressure measured at four different physical examinations over a 10-year period, 110 events of definite coronary heart disease (CHD) occurred during 11.6 years of subsequent follow-up. Each subject's mean blood pressure, the slope of the regression of his blood pressure on age, and the variance of blood pressure about this regression line were tested for association with subsequent incident definite CHD. Adjusted for mean systolic blood pressure (SBP), the variance of SBP was significantly associated with CHD (p < 0.001); however, the slope was not significantly associated with CHD. Variation in body weight was an independent risk factor for CHD. The effect of variation in SBP was significantly higher among men not taking antihypertensive medication; among men taking antihypertension medication, the standardized relative risk was 1.00. Comparing men in the highest quintile of SBP variation with those in the lowest quintile, the relative risk of CHD was 2.0 among all subjects and 5.3 among the 1,007 men not taking antihypertensive medication (95% confidence interval 1.8-15.4). Some of the beneficial effect of taking antihypertensive medication may have been due to reducing the effect of SBP variance rather than simply lowering the average SBP.

Visualization of compression neuropathies through volume deformation

This paper describes an interdisciplinary effort to simulate and visualize the mechanisms involved in compression neuropathies, specifically tissue deformation occurring during vaginal delivery. These neuropathies often evolve into chronic pelvic pain. We present our methodologies of using high resolution magnetic resonance acquisitions from submillimeter pulse sequences to develop interactive computer simulations based on physically plausible volume models to drive 3D simulations of childbirth. This effort will elucidate tissue movements and mechanics involved in pain disorders and better explain the etiology of these disorders.

Predictors of myocardial lesions in men with minimal coronary atherosclerosis at autopsy. The Honolulu heart program

Some cardiovascular risk factors are associated with clinical coronary heart disease but not with autopsy evidence of coronary atherosclerosis. To determine whether these risk factors might operate through mechanisms other than atherosclerosis, we examined associations between cardiovascular risk factors and subsequent intramural myocardial lesions assessed by protocol autopsy between 1965 and 1984 in 120 Japanese-American men from the Honolulu Heart Program who had minimal coronary atherosclerosis (American Heart Association (AHA) panel score < 3 on scale of 1 to 7). Age-adjusted prevalence of myocardial lesions was related to smoking status (P < 0.01), as well as amount, duration, and pack-years of smoking (P < 0.03). In a multiple logistic model, smoking (20 pack-years) was directly associated and fish intake (> or = 2 times/wk) was inversely associated with myocardial lesions independently of age, cholesterol, systolic blood pressure, body mass index, alcohol, diabetes, total calories, and animal protein intake (odds ratio (OR) = 1.5, 95% confidence intervals (CI) = 1.1 to 2.0 and OR = 0.35, 95% CI = 0.2 to 0.9, respectively). The protective effect of fish intake was most evident among men who did not have hypertension at baseline. Indices of obesity, body fat distribution, and physical activity and levels of triglyceride and alcohol intake were not associated with myocardial lesions. Thus, the adverse effects of smoking and the protective effects of fish consumption may extend to individuals relatively free of coronary atherosclerosis, possibly through hemostatic mechanisms or effects on small intramural arteries.

Low serum cholesterol and mortality. Which is the cause and which is the effect?

BACKGROUND

Many studies have reported an association between a low or lowered blood total cholesterol (TC) level and subsequent nonatherosclerotic disease incidence or death. The question of whether low TC is a true risk factor or alternatively a consequence of occult disease at the time of TC measurement remains unsettled. To shed new light onto this problem, we analyzed TC change over a 6- year period (from exam 1 in 1965 through 1968 to exam 3 in 1971 through 1974) in relation to subsequent 16-year mortality in a cohort of Japanese American men.

METHODS AND RESULTS

The study was based on 5941 men 45 to 68 years of age without prior history of coronary heart disease, stroke, cancer, or gastrointestinal-liver disease at exam 1 who also participated in exam 3 of the Honolulu Heart Program. The association of TC change with mortality end points was investigated with two different approaches (continuous and categorical TC change) with standard survival analysis techniques. Falling TC level was accompanied by a subsequent increased risk of death caused by some cancers (hemopoietic, esophageal, and prostate), noncardiovascular noncancer causes (particularly liver disease), and all causes. The risk-factor-adjusted rate of all-cause mortality was 30% higher (relative risk, 1.30; 95% CI, 1.06 to 1.59) among persons with a decline from middle (180 to 239 mg/dL) to low (< 180 mg/dL) TC than in persons remaining at a stable middle level. By contrast, there was no significant increase in all-cause mortality risk among cohort men with stable low TC levels. Nonillness mortality (deaths caused by trauma and suicide) was not related to either TC change or the average of TC levels in exams 1 and 3.

CONCLUSIONS

These results add strength to the reverse-causality proposition that catabolic diseases cause TC to decrease.

Serum total cholesterol and mortality. Confounding factors and risk modification in Japanese-American men

OBJECTIVE

To further investigate the relationship between serum total cholesterol (TC) level and mortality due to major causes. In particular, is the elevated mortality among persons with low TC levels due to confounding conditions that both lower TC level and increase the risk of mortality, and is the association between low or high TC level and mortality homogeneous in the population or, alternatively, restricted to persons with other risk factors?

STUDY DESIGN

Prospective cohort study.

SETTING

Free-living population in Oahu, Hawaii.

PARTICIPANTS

A total of 7049 middle-aged men of Japanese ancestry.

MAIN OUTCOME MEASURES

Age- and risk factor-adjusted mortality due to coronary heart disease, hemorrhagic stroke, cancer, chronic obstructive pulmonary disease, nonmalignant liver disease, trauma, miscellaneous and unknown, and all causes.

RESULTS

During 23 years of follow-up, a total of 1954 deaths were documented (38% cancer, 25% cardiovascular, and 37% other). Men with low serum TC levels (< 4.66 mmol/L [< 180 mg/dL]) were found to have several adverse health characteristics, including a higher prevalence of current smoking, heavy drinking, and certain gastrointestinal conditions. In an age-adjusted model, and in relation to the reference group (4.66 to 6.19 mmol/L [180 to 239 mg/dL]), those in the lowest TC group (< 4.66 mmol/L [< 180 mg/dL]) were at significantly higher risk of mortality due to hemorrhagic stroke (relative risk [RR], 2.41; 95% confidence interval [Cl], 1.45 to 4.00), cancer (RR, 1.41; 95% Cl, 1.17 to 1.69), and all causes (RR, 1.23; 95% Cl, 1.09 to 1.38). Adjustment for confounders in multivariate analysis (and exclusion of cases with prevalent disease at baseline and deaths through year 5) did not explain the risk of fatal hemorrhagic stroke but reduced the excess risk of cancer mortality by 51% (to 1.20 from 1.41) and reduced the excess risk of all-cause mortality by 56% (to 1.10 from 1.32) in the low TC group. In addition, there were clear differences in the patterns of risk when comparing men with and without selected risk factors (ie, smoking, alcohol consumption, and untreated hypertension).

CONCLUSIONS

We conclude that the excess mortality at low TC levels can be partially explained by confounding with other determinants of death and by preexisting disease at baseline, and TC-mortality associations are not homogeneous in the population. In our study, TC level was not associated with increased cancer or all-cause mortality in the absence of smoking, high alcohol consumption, and hypertension.

Serum cholesterol level and mortality due to suicide and trauma in the Honolulu Heart Program

BACKGROUND

Recent results from cholesterol level-lowering trials and some, but not all, observational studies support an intriguing link between low or lowered serum cholesterol levels and violent death. The reasons behind this relationship are far from clear.

METHODS

In this report, we further investigate this issue by assessing the relationship of baseline serum cholesterol levels with long-term risk of mortality due to trauma and suicide in a cohort of 7309 middle-aged Japanese-American men.

RESULTS

After 23 years of follow-up, a total of 75 traumatic fatalities and 24 deaths by suicide were documented. Rather than an inverse relation, a positive association between serum cholesterol level and risk of suicide death was observed. After controlling for potential confounders, the relative risk of suicide associated with an increment of 0.98 mmol/L (38 mg/dL) in serum cholesterol level (1 SD) was 1.46 (95% confidence interval, 1.04 to 2.05; P = .02). Multivariate analysis of traumatic mortality failed to detect a relation with serum cholesterol level (relative risk = 0.89; 95% confidence interval, 0.70 to 1.13; P = .44). Heavy alcohol consumption (> 1200 mL of alcohol per month, top quintile) was an independent risk factor for trauma death relative to abstinence (relative risk = 1.86; 95% confidence interval, 1.07 to 3.22; P = .02).

CONCLUSIONS

These findings contradict the hypothesis of an inverse relation between serum cholesterol level and suicide, but they support the hypothesis that heavy alcohol consumption is a risk factor for traumatic fatal events.

Lifestyle and biologic factors associated with atherosclerotic disease in middle-aged men. 20-year findings from the Honolulu Heart Program

OBJECTIVES

To examine the association between a variety of baseline lifestyle and biologic factors in a middle-aged cohort of Japanese-American men and the 20-year incidence rates of total atherosclerotic end points and each of the initial clinical manifestations of this disease, including fatal and nonfatal coronary heart disease, angina pectoris, thromboembolic strokes, and aortic aneurysms.

DESIGN

Prospective epidemiologic study.

POPULATION

Japanese-American men (N = 2710) between the ages of 55 and 64 years at the time of the initial clinical examination of the Honolulu Heart Program (1965 through 1968) free from evidence of coronary heart disease, cerebrovascular disease, cancer, or aortic aneurysms.

RESULTS

Among the men studied, 602 atherosclerotic events developed during the 23-year period of follow-up (1965 through 1988). After adjustment for each of the baseline characteristics examined, significant positive associations between quartile cutoffs of body mass index, systolic blood pressure, serum levels of cholesterol, triglycerides, glucose, and uric acid, as well as cigarette smoking, and the occurrence of any atherosclerotic end point were seen, while an inverse association with alcohol consumption was observed. Characteristics associated with the development of other fatal and nonfatal clinical events in this cohort, including coronary heart disease, thromboembolic stroke, and aortic aneurysms are presented with accompanying relative and attributable risks.

CONCLUSIONS

The results of this prospective epidemiologic study provide insights to the long-term predictive utility of the commonly accepted risk factors for coronary heart disease in relation to the different clinical manifestations of atherosclerosis in a middle-aged male cohort followed up for approximately 20 years. These results provide additional support for risk factor modification in middle-aged men and for the encouragement of positive long-term lifestyle changes.

Trends in stroke incidence and mortality in Hawaiian Japanese men

BACKGROUND AND PURPOSE

Vital statistics show a sharp decline in stroke mortality since the late 1960s. It is not clear whether this has been associated with a decline in stroke incidence.

METHODS

Since 1966 the Honolulu Heart Program has monitored the incidence and mortality of coronary heart disease and stroke in a target population of 11,136 men of Japanese ancestry living on Oahu. Trends were analyzed from January 1, 1969, through December 31, 1988.

RESULTS

Of 7893 men aged 45 to 68 years and free of stroke at entry examination, 530 developed first episodes of stroke in the period 1969 to 1988 (389 cases of thromboembolic stroke, 124 cases of hemorrhagic stroke, and 17 cases of stroke of unknown type). Age-adjusted annual stroke incidence declined from 5.1 per 1000 person-years in 1969 to 1972 to 2.4 in 1985 to 1988. The incidences of thromboembolic stroke, hemorrhagic stroke, and total stroke decreased 3.5%, 4.2%, and 4.4% per year, respectively. The 1-month case-fatality rates for thromboembolic stroke decreased moderately; those for hemorrhagic stroke fell dramatically.

CONCLUSIONS

These findings suggest that the decline in stroke mortality in the past two or three decades results from a decline in both incidence rates and early case-fatality rates in thromboembolic and hemorrhagic stroke and stroke of unknown type. The decreases may be related to changes in risk factors, such as the decline in blood pressure and the decrease in cigarette smoking, as well as improvements in diagnosis and treatment.

A prospective study of the health effects of alcohol consumption in middle-aged and elderly men. The Honolulu Heart Program

BACKGROUND

The study objective was to determine the association between reported alcohol consumption and total mortality, mortality from selected causes, and incident nonfatal chronic disease events in middle-aged (51 to 64 years old) and elderly (65 to 75 years old) men during an approximate 15-year follow-up period.

METHODS AND RESULTS

We conducted a prospective epidemiological study of Japanese-American men who were participating in the Honolulu Heart Program and were free from coronary heart disease, cerebrovascular disease, and cancer at baseline examination and at subsequent reexamination 6 years later. Self-reported alcohol consumption was determined twice: at the baseline examination in 1965 through 1968 and at reexamination approximately 6 years later (1971 through 1974). Four primary alcohol consumption groups who reported similar alcohol intake at the time of these two clinical examinations were considered: abstainers and light (1 to 14 mL of alcohol per day), moderate (15 to 39 mL of alcohol per day), and heavy (> or = 40 mL of alcohol per day) drinkers. Study end points were also determined in very light (1 to 4.9 mL of alcohol per day) drinkers and in men who reported a change in their alcohol intake between examinations. Longitudinal follow-up was carried out through the end of 1988 with determination of selected fatal and nonfatal events according to alcohol intake. After controlling for several potentially confounding factors, total mortality exhibited a J-shaped pattern in relation to alcohol consumption in middle-aged and elderly men. There was a trend for lower rates of occurrence of combined fatal and nonfatal coronary heart disease events with increasing alcohol consumption in both middle-aged and elderly men. Increasing alcohol consumption was related to an increased risk of fatal and nonfatal strokes in middle-aged men, whereas elderly light and moderate drinkers were at increased risk for fatal and nonfatal strokes. Heavy drinkers were at increased risk for fatal and nonfatal malignant neoplasms in the two age groups examined.

CONCLUSIONS

The results of this long-term prospective study provide a balanced perspective of the health effects of alcohol consumption in middle-aged and elderly men. High levels of alcohol consumption were shown to be related to an increasing risk of diseases of considerable public health importance. These findings suggest that caution be taken in formulating population-wide recommendations for increases in the population levels of alcohol consumed given the associated significant social and biological problems of high consumption levels.

SCP-Related Peptides From Bivalve Mollusks: Identification, Tissue Distribution, and Actions

The SCPs3 are a small peptide family, characterized in gastropods, and implicated in the control of the cardiovascular system and the muscles involved in feeding and gut motility. We aimed to determine the manifestation of this peptide family in the class Bivalvia. Acetone extracts of whole bivalves were fractionated by high pressure liquid chromatography (HPLC), and reactive peaks were identified by radioimmunoassay (RIA). After purification, sequencing, and analysis by mass spectroscopy, three peptides were identified in the clam Mercenaria mercenaria: IAMSFYFPRMamide, AMSFYFPRMamide, and YFAFPRQamide4. SCP-related peptides from two other species were also sequenced: APKYFYFPRMamide and SAFYFPRMamide from an oyster, Crassostrea virginica; and AMSFYFPRMamide (identical to one of the clam peptides) from a cockle, Dinocardium robustum. The tissue distribution and pharmacological actions of the clam SCPs were determined in M. mercenaria, as follows. The levels of peptide in extracts of 12 tissues were estimated by RIA. The largest concentrations of SCP occur in the palps and the visceral ganglia; the levels in the cerebral and pedal ganglia, the rectum, intestinal typhlosole, and gills were substantially lower; and the smallest amounts were found in the heart and the style sac typhlosoles. Immunohistochemistry revealed many cell bodies in the periphery of the ganglia and fibers in the neuropil. Immunoreactive, varicose fibers also occur in the typhlosoles of the intestine and style sac, and in the rectum, gill, and palps. The atrioventricular valves, but not the atria or ventricle proper, contain immunoreactive fibers. Synthetic clam SCPs were assayed on the rectum, the typhlosoles of the intestine and style sac, and the ventricle, all isolated in an organ bath. At low to moderate doses, the SCPs relaxed the muscles of the rectum; higher doses had biphasic actions. The muscles of the intestinal and style sac typhlosoles were relaxed, and spontaneous rhythmicity was slowed by the SCPs. Most ventricles were unresponsive. We conclude that the SCPs isolated in bivalves--though distinctive--are true homologs of those in gastropods. Moreover, the bivalve peptides also serve similar roles, controlling feeding and digestion, and perhaps even cardioactivity.

Determinants of the prognosis after a first myocardial infarction in a migrant Japanese population. The Honolulu Heart Program

BACKGROUND

Although numerous studies have been published on the prognostic assessment of myocardial infarction, little is known about determinants of the prognosis after a first myocardial infarction, especially regarding the role of standard risk factors for coronary heart disease (CHD) measured before the development of myocardial infarction.

METHODS AND RESULTS

In a prospective study of CHD among men of Japanese ancestry living in Hawaii, 457 patients with a first myocardial infarction (age range, 46 to 84 years) were identified during 20 years of follow-up. The relations of clinical variables and CHD risk factors to mortality in early (< 30 days) and two stages of late (30 days to 5 years and 5 to 10 years) periods after myocardial infarction in these patients were investigated. In multivariate analyses using logistic regression models (for early mortality) and Cox regression models (for late mortality), age at myocardial infarction and severe complications (Killip classes 3 and 4) were independent predictors of both early and late mortality (up to 5 years after myocardial infarction). In addition, ventricular arrhythmias predicted only early mortality, whereas anterior myocardial infarction, radiological evidence of cardiomegaly and/or pulmonary congestion, and intraventricular block predicted only late mortality (up to 5 years after myocardial infarction). Only age was an independent predictor of all-cause mortality more than 5 years after myocardial infarction. After adjusting for age at myocardial infarction and these clinical variables, preinfarction-measured risk factors such as 1-hour postload serum glucose (positively) and 1-second forced expiratory volume (inversely) were significantly associated with late mortality up to 5 years, whereas systolic blood pressure was the only independent predictor of late mortality after 5 years.

CONCLUSIONS

This study has confirmed the importance of age at myocardial infarction and clinical indicators of complications such as Killip class 3 or 4, radiological evidence of pulmonary congestion, and ventricular arrhythmias or intraventricular block as the prognostic determinants of myocardial infarction. In addition, some of the preinfarction-measured standard risk factors for CHD were found to predict long-term prognosis independent of age and clinical factors.

Sugarcane workers: morbidity and mortality

Sugarcane is, after pineapple, the largest agricultural industry in Hawaii. There have been reports that this industry poses certain health hazards. To investigate this possible hazard in Hawaii, the relationship of employment on a sugarcane plantation to total mortality, the development of definite coronary heart disease (CHD), stroke, cancer, lung cancer and certain risk factors were examined in men of Japanese ancestry participating in the Honolulu Heart Program. After 18 years of follow-up, those men who indicated one or more years working on sugarcane plantations had no significant difference in age-adjusted mortality, nor incidence of CHD, stroke, cancer, or lung cancer. There were no differences in risk factors compared to participants who were never employed on sugarcane plantations, nor were there differences in lung function as measured by FEV1. These findings were unchanged after adjusting for several potential confounding variables. No cases of mesothelioma were observed among those with a history of defined exposure. These findings were not due to a "healthy worker bias" and indicate that employment on a sugarcane plantation in Hawaii is not associated with elevated rates of chronic diseases.

Mortality and morbidity among blue and white collar workers in the Honolulu Heart Program cohort

There has been a controversy regarding occupation, as defined by blue and white collar work, and coronary heart disease (CHD). In a large long-term prospective study of the Honolulu Heart Program cohort, there were no significant differences between these two occupational classifications and the incidence rates of fatal and non-fatal CHD. Nor were there significant differences in total mortality, stroke or total cancer although there were very small but significant differences in some CHD risk factors. Unlike the previous studies, this investigation was free of prevalent cases of CHD at baseline and controlled for the major risk factors of CHD. We question the utility of using this occupational classification to investigate the causes of CHD.

Association of diabetes mellitus with coronary atherosclerosis and myocardial lesions. An autopsy study from the Honolulu Heart Program

While the excess risk of clinical cardiovascular disease among persons with diabetes mellitus is well established, most autopsy studies have not been able to elucidate reasons for the excess, to assess potential selection bias, or to adjust for other cardiovascular risk factors. The purpose of this study was to examine the predictive relation between diabetes and autopsy evidence of coronary atherosclerosis and myocardial lesions. Among 8,006 Japanese-American men examined at baseline in 1965-1968 as part of the Honolulu Heart Program, 7,591 were free of cardiovascular disease, and 1,515 of these men died over a 17-year follow-up period. Protocol autopsies were performed for 83 diabetic men and 159 nondiabetic men. Diabetes status was defined using self-reported history and treatment at several examinations, as well as physician diagnoses during hospitalization between 1965 and 1984. An excess of coronary artery atherosclerosis, assessed by mean panel score (3.4 vs. 3.0, p = 0.017) and percentage of intimal surface with raised lesions (56.6% vs. 47.4%, p = 0.024), was present among diabetic men but diminished to nonsignificant levels (3.3 vs. 3.0, p = 0.102, and 53.9% vs. 48.8%, p = 0.183, respectively) after adjustment for other cardiovascular risk factors. Myocardial lesions (acute, healing, or fibrotic) occurred significantly more frequently among diabetics than among nondiabetics (77.7% vs. 63.4%, p = 0.035), even after adjustment for other risk factors. Potential autopsy selection bias assessed in several ways appeared minimal. Among men with mild atherosclerosis, diabetics had more small and large myocardial lesions than did nondiabetics, although differences were not statistically significant (p < 0.10). It appears that the more adverse risk factor profile among diabetics accounts for some of the observed excess of coronary atherosclerosis. However, diabetes was independently associated with myocardial lesions, and these findings suggest a role for nonatherosclerotic mechanisms, such as clotting abnormalities or microvascular disease, in accounting for the excess clinical heart disease found in persons with diabetes.

Dehydroepiandrosterone sulfate, incidence of myocardial infarction, and extent of atherosclerosis in men

BACKGROUND

Antiatherogenic effects of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS) have been suspected for more than 30 years, yet the available evidence to support or refute such effects in humans is inconclusive. The hypothesis has not been adequately tested in large-scale epidemiological studies.

METHODS AND RESULTS

The present study used a cohort of men initially free of clinically detectable coronary heart disease, stroke, and cancer to compare DHEAS levels measured in sera obtained in 1968-1971 between 238 cases who had definite coronary heart disease during the subsequent 18 years and 476 age-matched controls who survived the follow-up period and remained free of clinically detectable coronary heart disease. In a separate study, the relation of DHEAS levels to extent of atherosclerosis was examined among 82 cohort men who died during the follow-up period and had protocol autopsies. Age-adjusted DHEAS levels were lower among fatal cases of coronary heart disease than among controls (94.7 versus 106.9 micrograms/dl, respectively; p < 0.05). After adjustment for eight coronary risk factors, the odds ratio for fatal coronary heart disease comparing a 100-micrograms/dl difference in DHEAS level was 0.46 (95% confidence intervals, 0.19-1.07). In contrast, age-adjusted DHEAS levels did not significantly differ between nonfatal cases of myocardial infarction and controls (107.2 versus 106.9 micrograms/dl, respectively). Furthermore, DHEAS levels were not related to extent of atherosclerosis at autopsy.

CONCLUSIONS

These findings do not support a role of DHEAS in the development of nonfatal myocardial infarction or the progression of atherosclerosis. The association of DHEAS with fatal coronary heart disease and possibly with death from all causes merits further investigation. These findings suggest continued skepticism that DHEAS has an important role in coronary disease etiology or prevention.

Will lowering population levels of serum cholesterol affect total mortality? Expectations from the Honolulu Heart Program

Major campaigns now underway to reduce the serum cholesterol levels of entire national populations have not given serious consideration to the high rates of noncardiovascular disease and death associated with low cholesterol levels (less than 190 mg/dl). To explore this problem, the relationships between serum cholesterol levels, measured in 1965-1968 in 7478 Japanese American men in Hawaii, and subsequent total and cause-specific mortality through 1985, were analyzed by multivariate Cox regression to control for potential confounders. Total mortality rates for 1648 deaths showed a U-shaped curve by baseline cholesterol level, with significant inverse trends (p less than 0.03) for deaths due to hemorrhagic stroke, all cancer, benign liver disease, chronic obstructive lung disease and "unknown cause". Only the inverse trends for cancer and benign liver disease showed flattening when 227 deaths in the first 5 years of follow-up were deleted from the analysis. Simulation models using three different strategies of cholesterol reduction in this cohort revealed that none of these approaches had any substantial impact on predicted total mortality over 15 years. However, the population-based approach might theoretically increase mortality for 60% of the cohort with baseline cholesterol levels less than 225 mg/dl.

Lipoproteins and blood pressure as biological pathways for effect of moderate alcohol consumption on coronary heart disease

BACKGROUND

Several epidemiological studies have shown light-to-moderate alcohol consumption to have a net protective effect on the incidence of coronary heart disease (CHD).

METHODS AND RESULTS

Major components of this effect, both positive and negative, may be explored using models that include both alcohol and variables expected to mediate the observed alcohol effect. Such modeling in a cohort of men of Japanese descent followed in the Honolulu Heart Program indicates that about half of the observed protection against CHD afforded by moderate alcohol consumption is mediated by an increase in high density lipoprotein cholesterol. An additional 18% of this protection is attributable to a decrease in low density lipoprotein cholesterol, but it is counterbalanced by a 17% increase in risk due to increased systolic blood pressure. The explanation for the residual 50% benefit attributable to alcohol is unknown but may include interference with thrombosis. The results in this population replicate those in the Lipid Research Clinics cohort studied earlier with the same analytic technique.

CONCLUSIONS

The consistency of these findings across populations, along with the demonstration of reasonable biological pathways for this effect of alcohol, provides strong support for the hypothesis that light-to-moderate alcohol intake is protective against heart disease in men.

Smoking, pulmonary function, and mortality

The association of pulmonary function (as percent of predicted forced expiratory volume in 1 second [FEV1]) with total and cause-specific mortality over 15 to 18 years was investigated in a large cohort (5924) of prospectively followed Japanese-American men. Among those who never smoked, pulmonary function was found not to be significantly predictive of total mortality in a multivariate model in which adjustment for variables that might confound the results was made. Among past and current smokers, highly significant associations were found (P < 0.0001). The positive relationship of pulmonary function to mortality in smokers was so strong that it overshadowed these differences in nonsmokers in a model including all smoking groups combined, even after adjusting for smoking. A smoking-pulmonary function interaction term added to this model was statistically significant (P < 0.003). This illustrates the need for attention to the potential for complex interactions between biologic variables when carrying out multivariate statistical analysis. Findings for cardiovascular and noncardiovascular mortality were similar. This analysis indicates that while pulmonary function is associated with subsequent mortality, the relationship is significantly associated with smoking history.

Health status and life style in elderly Japanese men with a long life expectancy

The Japanese population in Hawaii has one of the longest life expectancies of any large population subgroup in the U.S. and the world. Cross-sectional data on 1,379 elderly, noninstitutionalized, male Japanese American survivors of a population-based cohort study indicated the most common health problems were hypertension (43%), arthritis (33%), diabetes (13%), and gout (9%). For cancer and hypertension there is a trend toward higher prevalence in older age groups. For coronary heart disease, stroke, and angina the oldest age group (75-81 years) has a higher prevalence than that seen in younger age groups. Other relatively common diseases such as diabetes, gout, peptic ulcer, and arthritis do not have higher prevalence in older age groups. Drugs reported to be used frequently by study participants were for hypertension, gout, CHD, and diabetes. The prevalence rates of major limitations of mobility and of living alone appear to be relatively low in this population. Less than one percent of the current population rate their health status as poor. The prevalence of normal serum cholesterol and smoking are similar to those seen in U.S. White males, while the rates of hypertension appear lower. Prevalence rates for stroke and heart attack also appear to be somewhat lower in these long-lived individuals than those seen in U.S. Whites.

Potential bias due to prevalent diseases in prospective studies

In prospective studies, subjects found to have the disease under investigation at the initial screening examination are commonly excluded from analyses. However, the possibility of bias due to prevalent conditions other than the disease of interest is usually not considered. In the present study, an algebraic development enables analysis of the effects of inclusion and exclusion of subjects with certain prevalent conditions upon risk estimates. Hypothetical data are presented for which an association between a risk factor and an incident disease could become null or even reversed after removing subjects with certain prevalent diseases. Bias appears even when the only association present is between risk factor and total disease incidence. Data from the Honolulu Heart Study also have been used to illustrate this finding, examining the association between coronary heart disease (CHD) incidence and smoking. Decisions regarding the inclusion or exclusion of subjects with prevalent diseases requires prior knowledge of alteration of usual risk factors levels by individuals with these diseases. Simply removing all subjects with prevalent diseases might on the contrary create bias. Therefore, people with prevalent diseases should be screened for potential alteration of their risk factor levels as a result of the diseases. The situation becomes still more complex when several risk factors and prevalent diseases need to be considered at the same time as it happens in multivariate analyses. Because this situation represents a bias, and not confounding or effect modification, controlling for the effect of prevalent diseases is not appropriate.

The paradox of high risk of stroke in populations with low risk of coronary heart disease

The "paradoxical" occurrence of high rates of stroke and low rates of coronary heart disease observed in Asian and other populations has been examined using accumulated clinical and autopsy data obtained during the long-term follow-up from 1965 to 1985 of cohorts of Japanese men living in Hawaii and Japan. The search for explanatory variables revealed three with the characteristics of having both opposing patterns of associations with clinical stroke compared with coronary heart disease and of being more prevalent in Japan than in Hawaii. These variables were low serum cholesterol levels, high intake of alcohol, and some aspect of an Oriental diet characterized by low intake of fat and protein from animal sources. Analysis of associations of these variables with measures of atherosclerosis in coronary and cerebral arteries revealed no paradoxical differences, with the possible exception of some dietary variables. Associations with autopsy-measured myocardial infarctions, cerebral infarction, and hemorrhage, however, showed opposing patterns similar to those found for clinical disease. The main inference from this work is that the paradoxically high risk of stroke observed in populations with low risk of coronary heart disease is not due to atherosclerosis in the major cerebral arteries. Rather, it is more likely due to lesions in the small intracerebral arteries and appears to be related to low levels of serum cholesterol, high alcohol intake, and some aspect of a traditional Oriental diet.

Serum cholesterol and hemorrhagic stroke in the Honolulu Heart Program

During an average 18 years of follow-up for 7,850 Japanese-American men in Hawaii who were free of stroke at entry, 116 developed hemorrhagic stroke (subarachnoid hemorrhage or intracerebral hemorrhage). There was a significant (p = 0.001) inverse association between serum cholesterol and the risk of intracerebral hemorrhage but not of subarachnoid hemorrhage. This inverse association was nonlinear, with a higher incidence rate only for men with serum cholesterol in the lowest quintile (less than 189 mg/dl). The relative risk (lowest quintile/other four quintiles) was 2.55 (95% confidence interval 1.58-4.12) after controlling for age, blood pressure, serum uric acid, cigarette smoking, and alcohol consumption. There was no evidence for an interaction between blood pressure and serum cholesterol, although the inverse association was stronger for normotensive than for hypertensive men. Public health implications would differ in different countries depending on the relative frequency of intracerebral hemorrhage and on the distribution of serum cholesterol levels in the population.

Dietary alcohol, calcium, and potassium. Independent and combined effects on blood pressure

To determine whether or not the previously reported association between alcohol intake and high blood pressure is influenced by differential intake of calcium and potassium in drinkers compared with nondrinkers and to assess the magnitude of the independent contributions of alcohol, calcium, and potassium to blood pressure, these associations were evaluated in 7,011 men of Japanese descent. Categorical analyses and multiple linear regression techniques were used to test the hypotheses that alcohol, calcium, and potassium were independent predictors of blood pressure. Alcohol consumption above a threshold of approximately 20 ml/day was found to be positively, strongly, and independently correlated with systolic and diastolic pressures, and this effect was completely independent of the effects of calcium and potassium. Calcium and potassium intake were highly correlated (r = 0.59) and were inversely related to blood pressure, and their combined effect was greater than the effect of either alone. However, in the subgroup of moderate and heavier drinkers, only potassium was inversely related to blood pressure. This finding is compatible with previous reports of malabsorption and increased excretion of calcium at higher levels of alcohol intake, and it indicates that a small portion of the alcohol-induced blood pressure elevation may be mediated through calcium depletion. In the range of dietary intake in this cohort, the effect of alcohol on blood pressure was stronger than was either the separate or combined effects of calcium and potassium.

Predictors of sudden cardiac death among Hawaiian-Japanese men

A cohort of 7,591 middle-aged Hawaiian-Japanese men free at initial examination of evidence of coronary heart disease or stroke were followed starting in 1965. Between 1965 and 1983, 1,342 of these men died; 229 deaths occurred less than 24 hours after the onset of the terminal episode, of which 98 deaths occurred in less than one hour. In the category of deaths occurring less than one hour after onset, the risk characteristics of those whose deaths were attributed to coronary heart disease and those whose deaths were attributed to an unknown cause were similar. It is appropriate to combine them as "sudden cardiac death." In the category of deaths occurring one to 24 hours after onset, the risk characteristics of those whose deaths were attributed to coronary heart disease and those whose deaths were attributed to an unknown cause differed. It is not appropriate to assume coronary heart disease as the underlying cause of death in this unknown cause group. The predictors of sudden cardiac death were blood pressure, serum cholesterol, serum glucose, cigarette smoking, history of parental heart attack, and electrocardiographic evidence of left ventricular hypertrophy or strain. Inversely related to risk were alcohol intake and the number of years spent in Japan. No factor distinguished those at risk for sudden cardiac death from those at risk for other manifestations of coronary heart disease.

Serum lipids and lipoproteins as predictors of atherosclerosis. An autopsy study

A prospective study of autopsy-determined measures of atherosclerosis in aortas and coronary and cerebral arteries was completed for a group of 83 men who were free of clinical cardiovascular disease and cancer when they entered the Cooperative Lipoprotein Phenotyping Study in 1970. Total cholesterol minus high density lipoprotein cholesterol (HDL-C) was significantly associated with measures of atherosclerosis in all three groups of vessels. The patterns of associations for total, low density lipoprotein, and very low density lipoprotein cholesterol were similar but generally weaker and not significant for atherosclerosis in the cerebral arteries. Inverse associations of HDL-C with atherosclerosis in the circle of Willis and aorta were significant, but those for the coronary arteries were not. These associations were independent of other major risk factors for atherosclerosis in multivariate analyses. Similarities between these findings and those for clinical cardiovascular disease in the same cohort indicate that the opposing patterns of increased risk of clinical cardiovascular disease associated with total cholesterol and the decreased risk associated with HDL-C also exists at the level of atherosclerosis in a variety of arteries.

Occupational strain and the incidence of coronary heart disease

The hypothesis that men in high "strain" occupations have an increased risk of developing coronary heart disease was tested during an 18-year follow-up study from 1965-1983 of a cohort of 8,006 men of Japanese ancestry in Hawaii. There were no significant associations between the incidence of coronary heart disease and the individual job components of high psychologic demands and low job control or for the high strain interaction of these two characteristics. There were, in fact, trends of associations opposite to that predicted by the job strain model which were of borderline significance in multivariate analyses. Stratified analyses by level of acculturation showed similar inverse associations of job strain and coronary heart disease for the more Westernized men and no association for the more traditional men. There were also no significant associations among the various job characteristics and the major risk factors for coronary heart disease in this cohort. The disagreement of these results with those from other studies may be due to methodologic differences of using men whose usual and current occupations were the same in this study compared with using only current occupation in the other studies, the use of different methods of measuring job strain, or the possibility that men in this cohort perceive or react to occupational strain differently.

Risk factors in middle age that predict early and late onset of coronary heart disease

Twelve biological and lifestyle characteristics measured in a group of 5919 middle aged men free of clinical coronary heart disease (CHD), stroke and cancer were analyzed for differences in predicting early and late onset of new cases of definite CHD (non-fatal myocardial infarction and fatal CHD) over a 12-year follow-up period. Among these men, 151 cases of definite CHD occurred early (under age 60) and 135 cases occurred later in life (age 60 and over). Serum triglyceride was the only risk factor that was an independent predictor of early onset disease and not of late onset disease. While cigarette smoking was a predictor for both onset groups, the effect of smoking was greater in people who developed CHD earlier in life. Systolic blood pressure, alcohol intake, serum cholesterol and serum glucose were independent predictors for both onset groups, with no difference in effect between groups. The findings indicate that it is possible for some factors to affect CHD risk differently in terms of premature vs delayed onset of disease. The findings for serum triglyceride may account for some of the inconsistencies in reports regarding it as an independent risk factor for CHD. In general, however, most of the characteristics studied here had a similar effect on both early and late onset and thus remain important in the prevention of both premature and late onset of CHD.

Pulmonary function as a predictor of coronary heart disease

The role of pulmonary function as an independent predictor of coronary heart disease was examined in 1965-1983 in a cohort of Japanese-American men. As part of the Honolulu Heart Program, the authors measured pulmonary function in 5,924 men aged 45-68 years who were free of coronary heart disease at baseline examination and followed them for 15-18 years for the development of nonfatal myocardial infarction and fatal coronary heart disease. Per cent predicted forced expiratory volume in one second (%PFEV1) was significantly inversely related to coronary heart disease incidence in the total cohort after adjusting for age (p less than 0.0001) and then for all known coronary heart disease risk factors (p = 0.0004). However, when examined by smoking status, %PFEV1 was a predictor of coronary heart disease only among past and current smokers, and not for men who had never smoked cigarettes (p = 0.36). The association between pulmonary function and coronary heart disease can be explained by cigarette smoking, which leads to both lung impairment and coronary heart disease incidence.

Correlates of FEV1 and prevalence of pulmonary conditions in Japanese-American men

Correlates of forced expiratory volume in one second (FEV1) and the prevalence of pulmonary disease and symptoms were examined in 6,346 Japanese-American men 45 to 68 yr of age. There was a significant inverse dose-response relationship between FEV1 and cigarette smoking measured as pack-years, number of cigarettes, or number of years smoked. Ex-smokers had FEV1 values that were intermediate to the higher values for nonsmokers and the lower values for current smokers. Among current smokers, inhaling and starting to smoke at a younger age were associated with lower values of FEV1, independent of pack-years. FEV1 was also correlated with a variety of other biologic and sociobehavioral variables, even after removing the effects of smoking. These variables included skinfold thickness, dynamometry, hematocrit, triglycerides, and systolic blood pressure. When compared with Caucasian populations, these Japanese-American men had low prevalence rates of airflow obstruction and pulmonary disease symptoms.

A prospective study of mortality and morbidity among carpenters in the Honolulu Heart Program Cohort

The relationship of occupation as a carpenter to the development of definite coronary heart disease, stroke, cancer and total mortality was examined in men of Japanese ancestry participating in the Honolulu Heart Program. After 18 years of follow-up those men who indicated that their present and usual occupation was carpentry had a significantly lower age-adjusted rate of definite coronary heart disease and a significantly lower mortality rate compared to participants who were never occupied as carpenters. There were no significant differences for age-adjusted rates for stroke and cancer nor any differences for those whose usual occupation was carpentry but present occupation was not carpentry. These results were unchanged when controlling for several cardiovascular risk factors and potentially confounding variables. Unlike earlier observations, these findings are not affected by the "healthy worker bias" and support the relationship that carpentry is associated with lower rates of cardiovascular disease.

Comparison of two measures of atherosclerosis in a prospective epidemiology study

Two different methods of measuring atherosclerosis, the American Heart Association panel method and the International Atherosclerosis Project unaided visual estimation, were used to estimate the extent of atherosclerosis in the coronary arteries and aortas from 225 men who participated in a prospective study of cardiovascular disease. The two methods produced quite different results of frequency distribution of levels of atherosclerosis. The correlations of the two measures of atherosclerosis were also relatively low for both the coronary arteries (0.63) and the aortas (0.74). The correlation of atherosclerosis with major risk factors was generally higher with the unaided visual estimation method than with the panel method, except for cigarette smoking. However, the associations of coronary atherosclerosis with autopsy-documented myocardial infarction and with clinical coronary disease were similar for the two measures. Thus, it is clear that the estimate of extent of atherosclerosis and its associations with major risk factors depends upon the method used to measure atherosclerosis. Epidemiologic studies that use only one method may miss some types of risk factor associations.

Blood pressure, nephrosclerosis, and age autopsy findings from the Honolulu Heart Program

The aspect of nephrosclerosis reflected by fibrous intimal thickening of small arteries (arteriosclerosis) was measured by a newly introduced morphometric procedure in 154 autopsies of Japanese-American men in Honolulu. These men were subjects of the Honolulu Heart Program and had previously been assessed for blood pressure and other clinical characteristics in a prospective study. In periodic acid-Schiff (PAS)-stained sections of renal cortex, measurements were made of interlobular artery diameters and intimal thicknesses. Vessels of outer diameter 80 to 130 microns and 160 to 300 microns were examined separately and are called the "remote" and "close" levels of the interlobular arteries, respectively, defined in relation to the heart. Nephrosclerosis thus quantified, together with age, could be used to predict the levels of blood pressure (BP) to be found in retrospective review of past records. The mathematical function obtained in a former study to make these predictions was found to predict the observed levels of blood pressure to an acceptable degree in the groupings that involved 92% of the subjects. Verification of that formerly obtained predictive function is now claimed. Correlation coefficients relating BP to close and remote measures were about of equal magnitude (r = 0.34 and 0.40, respectively). Subjects with cardiovascular-renal causes of death differed in both nephrosclerosis and blood pressure from subjects whose cause of death was unrelated to cardiovascular-renal diseases; the two factors taken together each contributed significantly to the cause of death difference. Correlations between nephrosclerosis and aortic atherosclerosis were stronger than could be explained solely by a linkage to observed values of blood pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective study of cerebral artery atherosclerosis

Atherosclerosis in the circle of Willis and its major branches was studied prospectively in 198 men in the Honolulu Heart Program who were free of cardiovascular disease at the entry examination. The level of atherosclerosis was greater in the large arteries of the circle of Willis than in the small arteries, and autopsy-verified cerebral infarction was strongly associated with increasing severity of atherosclerosis in both. Analyses of the association of atherosclerosis scores with biologic and lifestyle characteristics measured at entry into the study indicated that atherosclerosis in the large arteries was consistently related to age, diastolic blood pressure, serum cholesterol, and height (inversely). Weak trends of association were also found with increasing serum glucose concentration, increasing cigarette use, and decreasing alcohol intake. Atherosclerosis scores in the small arteries were associated with diastolic blood pressure and serum triglyceride concentration. Analysis of dietary intake indicated that atherosclerosis scores were higher for men who reported low intakes of fat and animal protein and high intakes of vegetable protein and total carbohydrates. These patterns were consistent with similar findings on the incidence of clinical stroke in this cohort. Age-adjusted and -specific atherosclerosis scores from both the large and small arteries declined significantly during the period 1965-1983.

Physical activity and coronary heart disease in middle-aged and elderly men: the Honolulu Heart Program

The relationship of physical activity to the development of definite coronary heart disease was examined separately in middle-aged (45-64 years) and elderly men (65-69 years) participating in the Honolulu Heart Program. After 12 years of follow-up, results indicate that increased levels of physical activity reported at study entry were inversely related to the risk of definite coronary heart disease in both age groups. In particular, among those aged 45 to 64 years, the rate of definite coronary heart disease in men who led active life styles was 30 per cent lower than the rate experienced by those who were less active (relative risk, 0.69; 95% confidence interval, 0.53, 0.88). In those older than 64 years, the rate of definite coronary heart disease in active men was less than half the rate experienced by those who led more sedentary life styles (relative risk, 0.43; 95% CI, 0.19, 0.99). These results continued to hold up when controlling for several cardiovascular risk factors and potentially confounding variables, supporting earlier observations that physical activity is beneficial in middle-age, and further suggesting that benefits may extend to the elderly male population as well.

Predictive value of resting electrocardiograms for 12-year incidence of stroke in the Honolulu Heart Program

The importance of electrocardiographic (ECG) abnormalities at baseline examination for subsequent risk of stroke was analyzed in a 12-year follow-up of 7,560 men in the Honolulu Heart Program, aged 45-68 years, who were free of coronary heart disease and stroke at baseline. Age-adjusted univariate analysis showed that men with major ST depression, left ventricular strain, left ventricular hypertrophy, major T wave inversion, and overall major ECG abnormalities had considerably higher (2.5-5.4 times) incidence rates of both thromboembolic and hemorrhagic stroke than those with normal baseline ECG. When blood pressure, age, cigarette smoking, alcohol consumption, fat intake, serum glucose concentration, serum uric acid concentration, years of education, and years lived in Japan were taken into consideration through multivariate analysis, the ECG abnormalities retained a significant relation with stroke. Our study demonstrates that resting ECG abnormalities are independent predictors of both thromboembolic and hemorrhagic stroke.

A comparison of the 12-year mortality and predictive factors of coronary heart disease among Japanese men in Japan and Hawaii

The mortality and predictive factors of coronary heart disease among men of Japanese ancestry in Japan and Hawaii were compared on the basis of 12 years follow-up data using comparable methods of case ascertainment and risk factor measurements. Among 1,687 men (Japan) and 7,536 men (Hawaii) who were free of coronary heart disease and aged 45-69 at baseline examination in 1965-1968, 20 (Japan) and 123 (Hawaii) cases of fatal coronary heart disease were identified. The age-adjusted mortality rate was 40% higher in Hawaii than in Japan. The difference was not statistically significant, but consistent with earlier studies. More than half of this difference in mortality rate was attributed to different levels of known risk factors in the two cohorts. In multivariate analysis using the combined population, age, blood pressure, serum cholesterol, serum glucose, cigarette smoking, and alcohol intake (inversely) remained as significant predictors of coronary heart disease mortality. Although the associations of risk factors with coronary heart disease tended to be stronger in Hawaii than in Japan, there was no statistically significant difference in regression coefficient for any of the risk factors studied. These findings cannot be claimed to be definitive because of the small number of cases, especially in Japan.

The predictive value of resting electrocardiograms for 12-year incidence of coronary heart disease in the Honolulu Heart Program

The predictive value of electrocardiographic (ECG) abnormalities at baseline for subsequent risk of fatal and total coronary heart disease (CHD) was analyzed in a 12-year follow-up of 7682 men in the Honolulu Heart Program aged 45-68 who were free of CHD at baseline. Univariate analysis showed that men with major or minor ECG abnormalities, ST depression, high R wave, T-wave inversion, left ventricular hypertrophy or strain and premature ventricular contractions had considerably higher (2-10 fold) CHD incidence rates than those with normal ECG. When blood pressure, cigarette smoking, body mass index, alcohol use, physical activity, serum glucose, serum cholesterol, serum uric acid, age and years lived in Japan were taken into consideration through multivariate analysis, the ECG abnormalities retained significant associations with fatal and total CHD. This study demonstrated that resting ECG abnormalities were independent predictors of both total and fatal CHD.

Postmortem findings in sudden and non-sudden deaths among Japanese-American men in Hawaii

Analyses were made of the cause of death and major pathologic findings among 1,085 autopsied Japanese-American men in Hawaii to determine the differences between the 167 men who experienced sudden death within 24 hours of being well and the 918 men with non-sudden death. Sudden deaths were further divided into three subgroups according to the interval from the onset of symptoms to death: (less than one hour; one to six hours; more than six hours). Nearly 90 percent of sudden deaths and 25 percent of non-sudden deaths were attributed to cardiovascular disease. The proportion of deaths due to coronary heart disease was highest in sudden deaths less than one hour (72 percent) and lowest in sudden deaths more than six hours (49 percent), whereas the proportion of stroke deaths was highest in sudden deaths more than six hours (37 percent) and lowest in sudden deaths less than one hour (9 percent). The prevalence of myocardial infarction and the grade of coronary atherosclerosis were also significantly greater for sudden deaths (especially sudden deaths less than one hour) than for non-sudden deaths.

Predictors of atherosclerosis in the Honolulu Heart Program. II. Adjustment for autopsy bias

Although autopsy is considered the final word on many medical questions, there has long been concern over possible bias in inference about a living population from analysis of autopsy material. Focus of the present paper is on the relationship between results obtainable only at autopsy and risk factors recorded as part of a prospective study of the entire "target population." Since pathologies are sure to be overrepresented in an autopsy sample compared to the target population, the dependence of autopsy scores upon risk factors may be distorted in the autopsy sample. The present paper proposes a method of adjustment for this bias. When both autopsy sample and target population can be stratified by major disease categories, under certain assumptions of equal effect, adjustment similar to the direct method for age adjustment may be applied. If, in addition, dependence can be characterized accurately by linear regression of both autopsy score and disease category frequency onto risk factors, then a very convenient calculation produces adjusted regression coefficients. This "parametric" method usually provides the most convenient results, with the greatest statistical power.

Predictors of atherosclerosis in the Honolulu Heart Program. I. Biologic, dietary, and lifestyle characteristics

Of 8,006 men of Japanese ancestry living in Hawaii who were followed from 1966 to 1983 for incident cardiovascular disease, 1,381 died and 290 had a protocol autopsy which included determination of the extent of atherosclerosis in the coronary arteries and aorta. More than 50 biologic, lifestyle, and dietary characteristics, measured in 258 of the men who did not have existing evidence of definite coronary disease or stroke at the baseline examination, were examined for association with the measures of atherosclerosis using models which did and did not include adjustments for autopsy selection bias. Blood pressure and serum cholesterol were the strongest and most consistent predictors of atherosclerosis in both the coronary arteries and aortas. Cigarette smoking was also consistently associated with aortic atherosclerosis and inconsistently with coronary atherosclerosis. Several other variables often associated with clinical coronary artery disease in this cohort were not found to be independently associated with atherosclerosis. These included alcohol use, physical activity, serum glucose, triglyceride, and uric acid levels. None of more than 25 measures of dietary patterns and 24-hour dietary intake was associated with atherosclerosis in any statistical model. Examination of age-adjusted and age-specific levels of atherosclerosis over time from 1966 to 1983 showed a slight decrease in coronary atherosclerosis and a slight increase in aortic atherosclerosis; however, these trends were not significant. Both myocardial scars measured at autopsy and clinical evidence of myocardial infarction were significantly associated with the coronary atherosclerosis scores.