Sex differences in acute coronary syndrome management and in 12-month case-fatality trends: data from the French MONICA registries

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Santé publique France, U1167 - RID-AGE - Facteurs de risque et déterminants moléculaires des maladies liées au vieillissement, Lille, France.

Background

Earlier studies, have reported sex differences in clinical presentation, management and outcomes of acute coronary syndrome (ACS) which have prompted the medical community to take actions to erase these differences. To our knowledge, there has been no recent analysis of sex difference trends in ACS management, to assess whether these differences have been attenuated over time.

Aim

To assess recent sex differences trends in ACS characteristics, management and associated mortality.

Methods

We assessed all men and women (aged 35-74) hospitalized for an incident (first) ACS, in the 3 distinct geographical areas covered by the MONICA registries in the north, east and south-west of France, during a 12-month period in 2006 and a 6-month period in 2016. We analyzed the patients’ clinical, biochemical, electrocardiographic and care-related data, and their vital status 12 months after the ACS.

Results

We analyzed 2023 incident ACSs in 2006 and 1173 in 2016. The proportion of men was three times higher than that of women in both periods. In 2016, women were younger (62.0 y in 2006 and 60.4 y in 2016; p=0.06) and men were older (57.6 y in 2006 and 59.0 y in 2016; p<0.01). Women had no longer more atypical symptoms than men in 2016. In both men and women, the proportion of patients with NSTEMI increased from 26% in 2006 to 39% in 2016 (p<0.0001), whereas the proportion of patients with unstable angina decreased from 14% in 2006 to 7% in 2016 (p<0.0001). Between 2006 and 2016, the proportion of thrombolysis fell from 10% to 1% (p<0.0001); conversely, the proportion of patients receiving angioplasty increased from 67% to 75% (p<0.001). However, men were still more likely than women to receive revascularization therapy (+19% in 2006 and +18% in 2016). Between 2006 and 2016, prescriptions of angiotensin-converting enzyme inhibitors at discharge decreased from 68% to 64% (p< 0.01), and prescriptions of statins increased from 89% to 91% (p=0.02), as did prescription of functional rehabilitation from 34% to 40% (p<0.0001). Despite these trends, platelet aggregation inhibitors, statins and functional rehabilitation were still less prescribed in women than men in 2016 (p<0.01), independently of confounders. Finally, the 12-month case fatality rate was 11% in 2006 and 10% in 2016 (p=0.15), without sex differences.

Conclusions

The results of the present study evidenced an improvement over time in the management of ACS. However, although there were no longer sex differences in the patients’ age and clinical presentation, women with ACS were still less likely than men to receive revascularization and pharmacological treatments in 2016.

Long-term follow-up of incident acute coronary syndrome: results from the French MONICA registries over the 2009-2017 period

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Santé Publique France, U1167 - RID-AGE - Facteurs de risque et déterminants moléculaires des maladies liées au vieillissement, Lille, France.

Background

The prognosis of an acute coronary syndrome (ACS) is strongly affected by the clinical, biological, and angiographic features of the event. However, few studies have characterized long-term recurrences of ACS after an incident (first) event.

Aim

The goals of this study were (i) to estimate the long-term (9 years) risk of ACS recurrence, including fatal ACS recurrence, among survivors of a first-ever ACS, according to its diagnosis subtype (STEMI / NSTEMI / Unstable angina (UA)) and (ii) to identify factors associated with these risks.

Methods

We assessed all men and women (aged 35-74) hospitalized between January 2009 and December 2016 for an incident (first-ever) ACS, in the 3 distinct geographical areas covered by the MONICA registries in the north, east and south-west of France, and still alive at discharge (Index event). ACSs were classified as STEMI, NSTEMI and UA. Patients were followed-up until December 2017. Recurrent events were defined as the first non-fatal or fatal ACS occurring after hospital discharge from the index event. Multivariate Cox regression models were used to assess the relationships between recurrent ACS and variables of interest.

Results

A total of 15,739 incident ACSs were included. The study comprised a total of 63,777 patients-years and a median duration of follow-up of 3.8 [1.6-6.0] years. There were 1,963 (12,4%) recurrent ACSs of which almost half (1,046; 53%) occurred during the first year. The 1-, 5- and 9- year cumulative probabilities of recurrent ACS were 6.7% [6.3-7.1%], 13.4% [12.8-14.0%] and 18.4% [17.4-19.5%], respectively, and those of fatal recurrent ACS were 1.4% [1.2-1.5%], 2.7% [2.3-3.0%] and 4.3% [3.6-4.9%], respectively. Annual 1-year recurrence rates decreased between 2009 and 2016, from 7.4% to 4.0% (p Cochran-Armitage test <0.001). After an index STEMI and NSTEMI, the most frequent form of recurrent event was a NSTEMI, whereas UA was more likely event after an index UA. The age at the time of the event, the geographical region (North to South gradient), the presence of a major event (i.e. resuscitated cardiac arrest, acute pulmonary oedema or cardiogenic shock), and an impaired left ventricular ejection fraction (LVEF) were significantly associated with the risk of recurrence and fatal recurrence. ACS subtype was not associated with recurrent risk after adjustment for confounders.

Conclusions

In conclusion, after an incident ACS the recurrence rate remained elevated, with one in five patients experiencing a recurrent ACS during a 9-years follow-up. Half of recurrent events occurred within the first year after the index event and NSTEMI was the most frequent form of recurrent event. Age at the time of the event, region, major event and impaired LVEF are factors associated with a higher risk of recurrence, the most important one being an LVEF <35%.

Declines in in- and out-of-hospital coronary mortality from 2000 to 2016: results from the French MONICA registries

Background

In the past decades, improvements in the management of acute coronary events (ACE) have dramatically reduced in-hospital Coronary Heart Disease (CHD) mortality. Little is known on recent evolutions in out-of-hospital mortality and its contribution to overall ACE mortality.

Purpose

To estimate trends of in- and out-of-hospital ACE mortality rates from 2000 to 2016 and their respective contribution to total CHD mortality.

Methods

Using data from the three CHD MONICA registries, all fatal myocardial infarctions, coronary deaths and sudden deaths occurring between January 1st, 2000 and December 31st, 2016 in patients age 35 to 74 were recorded. Age-standardized mortality rates (SMRs) were estimated by gender and calendar year. Crude mortality rates (CMRs) were estimated by 20-years age group. Trends were expressed as annual percentage changes (APCs).

Results

During the study period, 20,822 fatal events were recorded, of which 69.4% took place out-of hospital (Figure 1). Almost 90% of out-of-hospital deaths occurred at home. Standardized ACE mortality rates decreased more steeply in women as compared to men, with an APC of −4.4%, versus −3.5% in men. Decreases in ACE mortality were more pronounced inside than outside the hospital (APC: −4.6% versus −3.1% in men; −5.9% versus −3.7% in women), with an increase in the contribution of out-of-hospital mortality to overall ACE mortality from 64.7% to 71.1% in men, and from 64.4% to 71.4% in women. Decreases in CMRs were more pronounced for people age 55–74 compared to those age 35–54. In the 55–74 age group, in-hospital SMRs decreased more steeply inside than outside the hospital (APC −5.2% versus −3.6% in men; −6.3% versus −3.9% in women, Figure 2). This was not observed among the youngest subjects, in whom the decreases for in- and out-of-hospital CMRs were similar (APC −1.5% versus −1.6% in men; −3.6% versus −3.1% in women).

Conclusions

Over the study period, out-of-hospital mortality accounted for more than two-thirds of overall ACE mortality. Declines were more pronounced for in-hospital mortality than for out-of hospital, except in the youngest subjects, in whom they were similar. These results highlight the need to strengthen primary prevention.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): - Santé Publique France (SPF) - Institut national de la santé et de la recherche médicale (Inserm)

A Role for Behavior in the Relationships Between Depression and Hostility and Cardiovascular Disease Incidence, Mortality, and All-Cause Mortality: the Prime Study

Background

Behavioral factors are important in disease incidence and mortality and may explain associations between mortality and various psychological traits.

Purpose

These analyses investigated the impact of behavioral factors on the associations between depression, hostility and cardiovascular disease(CVD) incidence, CVD mortality, and all-cause mortality.

Methods

Data from the PRIME Study (N = 6953 men) were analyzed using Cox proportional hazards models, following adjustment for demographic and biological CVD risk factors, and other psychological traits, including social support.

Results

Following initial adjustment, both depression and hostility were significantly associated with both mortality outcomes (smallest SHR = 1.24, p < 0.001). Following adjustment for behavioral factors, all relationships were attenuated both when accounting for and not accounting for other psychological variables. Associations with all-cause mortality remained significant (smallest SHR = 1.14, p = 0.04). Of the behaviors included, the most significant contribution to outcomes was found for smoking, but a role was also found for fruit and vegetable intakes and high alcohol consumption.

Conclusions

These findings demonstrate well-known associations between depression, hostility, and mortality and suggest the potential importance of behaviors in explaining these relationships.

Depression and mortality: artifact of measurement and analysis?

BACKGROUND

Previous research demonstrates various associations between depression, cardiovascular disease (CVD) incidence and mortality, possibly as a result of the different methodologies used to measure depression and analyse relationships. This analysis investigated the association between depression, CVD incidence (CVDI) and mortality from CVD (MCVD), smoking related conditions (MSRC), and all causes (MALL), in a sample data set, where depression was measured using items from a validated questionnaire and using items derived from the factor analysis of a larger questionnaire, and analyses were conducted based on continuous data and grouped data.

METHODS

Data from the PRIME Study (N=9798 men) on depression and 10-year CVD incidence and mortality were analysed using Cox proportional hazards models.

RESULTS

Using continuous data, both measures of depression resulted in the emergence of positive associations between depression and mortality (MCVD, MSRC, MALL). Using grouped data, however, associations between a validated measure of depression and MCVD, and between a measure of depression derived from factor analysis and all measures of mortality were lost.

LIMITATIONS

Low levels of depression, low numbers of individuals with high depression and low numbers of outcome events may limit these analyses, but levels are usual for the population studied.

CONCLUSIONS

These data demonstrate a possible association between depression and mortality but detecting this association is dependent on the measurement used and method of analysis. Different findings based on methodology present clear problems for the elucidation and determination of relationships. The differences here argue for the use of validated scales where possible and suggest against over-reduction via factor analysis and grouping.

Systemic chemokine levels, coronary heart disease, and ischemic stroke events: the PRIME study

OBJECTIVES

To quantify the association between systemic levels of the chemokine regulated on activation normal T-cell expressed and secreted (RANTES/CCL5), interferon-γ-inducible protein-10 (IP-10/CXCL10), monocyte chemoattractant protein-1 (MCP-1/CCL2), and eotaxin-1 (CCL11) with future coronary heart disease (CHD) and ischemic stroke events and to assess their usefulness for CHD and ischemic stroke risk prediction in the PRIME Study.

METHODS

After 10 years of follow-up of 9,771 men, 2 nested case-control studies were built including 621 first CHD events and 1,242 matched controls and 95 first ischemic stroke events and 190 matched controls. Standardized hazard ratios (HRs) for each log-transformed chemokine were estimated by conditional logistic regression.

RESULTS

None of the 4 chemokines were independent predictors of CHD, either with respect to stable angina or to acute coronary syndrome. Conversely, RANTES (HR = 1.70; 95% confidence interval [CI] 1.05-2.74), IP-10 (HR = 1.53; 95% CI 1.06-2.20), and eotaxin-1 (HR = 1.59; 95% CI 1.02-2.46), but not MCP-1 (HR = 0.99; 95% CI 0.68-1.46), were associated with ischemic stroke independently of traditional cardiovascular risk factors, hs-CRP, and fibrinogen. When the first 3 chemokines were included in the same multivariate model, RANTES and IP-10 remained predictive of ischemic stroke. Their addition to a traditional risk factor model predicting ischemic stroke substantially improved the C-statistic from 0.6756 to 0.7425 (p = 0.004).

CONCLUSIONS

In asymptomatic men, higher systemic levels of RANTES and IP-10 are independent predictors of ischemic stroke but not of CHD events. RANTES and IP-10 may improve the accuracy of ischemic stroke risk prediction over traditional risk factors.

Contribution of lifetime smoking habit in France and Northern Ireland to country and socioeconomic differentials in mortality and cardiovascular incidence: the PRIME Study

BACKGROUND

This study examines the contribution of lifetime smoking habit to the socioeconomic gradient in all-cause and smoking-related mortality and in cardiovascular incidence in two countries.

METHODS

10,600 men aged 50-59 years were examined in 1991-4 in centres in Northern Ireland and France and followed annually for 10 years. Deaths and cardiovascular events were documented. Current smoking habit, lifetime smoking (pack-years) and other health behaviours were evaluated at baseline. As socio-occupational coding schemes differ between the countries seven proxy socioeconomic indicators were used.

RESULTS

Lifetime smoking habit showed marked associations with most socioeconomic indicators in both countries, but lifetime smoking was more than 10 pack-years greater overall in Northern Ireland and smoking patterns differed. Total mortality was 49% higher in Northern Ireland than in France, and smoking-related mortality and cardiovascular incidence were 93% and 92% higher, respectively. Both lifetime smoking and fibrinogen contributed independently to these differentials, but together explained only 42% of the difference in total mortality between countries, adjusted for both biological and lifestyle confounders. Socioeconomic gradients were steeper for total and smoking-related mortality than for cardiovascular incidence. Residual contributions of lifetime smoking habit ranged from 6% to 34% for the seven proxy indicators of socioeconomic position for total and smoking-related mortality. Socioeconomic gradients in cardiovascular incidence were minimal following adjustment for confounders.

CONCLUSION

In Northern Ireland and France lifetime smoking appeared to explain a significant part of the gradients in total and smoking-related mortality between socioeconomic groups, but the contribution of smoking was generally small for cardiovascular incidence.

Predicting CHD risk in France: a pooled analysis of the D.E.S.I.R., Three City, PRIME, and SU.VI.MAX studies

BACKGROUND

We aimed to develop and validate a simple coronary heart disease (CHD) risk algorithm applicable to asymptomatic men and women in France, and to compare its accuracy with that of the last published version of the Framingham risk function for cardiovascular disease.

DESIGN

A pooled analysis of four French prospective general-population studies.

METHODS

The baseline and follow-up data from D.E.S.I.R., PRIME, Three City, and SU.VI.MAX studies were used. The 10-year CHD risk was estimated by the Cox proportional hazards model with candidate variables including age, gender, body mass index, waist circumference, family history of coronary heart disease, smoking status, diabetes status, systolic blood pressure, and total and high-density lipoprotein (HDL) cholesterol.

RESULTS

The study population included 22,256 subjects (61.4% men) aged (SD) 56.0 years (8.3) without a personal history of CHD at baseline. After a mean follow-up of 8.0 years (2.3), 788 first CHD events occurred, 726 in men and 62 in women. The final model included age, gender, age × gender interaction, current smoking status, diabetes status, systolic blood pressure, total and HDL cholesterol. Using this model, the number of predicted coronary events fitted that given by the 10-year Kaplan-Meier survival estimates within each decile of estimated risk (calibration). This model had fair discrimination: Harrell C-index, 0.7831 (95% CI: 0.7704-0.7957). For comparison, the recalibrated Framingham risk function had equivalent performances compared to the French risk equation.

CONCLUSION

Our 10-year French CHD risk equation based on traditional risk factors performed at least as well as the recalibrated Framingham cardiovascular disease risk function.

Association between the frequency of fruit and vegetable consumption and cardiovascular disease in male smokers and non-smokers

BACKGROUND/OBJECTIVES

Consumption of fruit and vegetables (F&V) is associated with a lower cardiovascular disease (CVD) risk. Smoking may affect the strength of this association. The objective of this study was to compare the relationship between the frequency of F&V intake and CVD risk in male current, former and never smokers.

SUBJECTS/METHODS

A prospective study in men (n=8060) aged 50-59 years who were recruited in France and Northern Ireland. The frequency of F&V intake was assessed by using a food frequency questionnaire. The outcome criteria were incident cases of acute coronary syndrome (ACS) and total CVD (coronary heart disease and stroke) over 10-year period.

RESULTS

A total of 367 ACS and 612 CVD events occurred during the follow-up period. A multivariate analysis revealed a statistically significant interaction between smoking status and F&V intake for ACS and for CVD (both P's<0.05). In current smokers, the relative risks for ACS were 0.78 (0.54-1.13) and 0.49 (0.30-0.81) in the second and third tertiles of F&V intake, respectively (P for trend<0.001); for CVD, the values were 0.80 (0.59-1.08) and 0.64 (0.44-0.93) respectively (P for trend<0.001). In contrast, no statistically significant associations were observed for never and former smokers. Similar statistical interactions for ACS were observed for fruit intake (P=0.07) and vegetable intake (P<0.05) taken separately.

CONCLUSIONS

These results suggest that high fruit and vegetable intake is associated with a lower risk of CVD in male smokers.

Anthropometric assessment of abdominal obesity and coronary heart disease risk in men: the PRIME study

OBJECTIVE

Waist-to-height ratio is an anthropometric indicator of abdominal obesity that accounts for stature. Earlier studies have reported marked associations between the waist-to-height ratio and cardiovascular risk factors. The goal of this study was to compare the associations of waist-to-height ratio, waist girth, waist-to-hip ratio or body mass index (BMI) with incidence of coronary events.

DESIGN

Prospective study with 10 602 men, aged 50-59 years, recruited between 1991 and 1993 in three centres in France and one centre in Northern Ireland. Clinical and biological data were obtained at interview by trained staff. During the 10 years of follow-up 659 incident coronary events (CHD) were recorded. The relations between anthropometric markers and coronary events were estimated by Cox proportional hazards models.

RESULTS

Waist circumference, waist-to-hip ratio, waist-to-height ratios and BMI were positively associated with blood pressure (p<0.0001), diabetes (p<0.0001), low-density lipoprotein (LDL)-cholesterol (p<0.0001), triglycerides (p<0.0001) and inversely correlated to high-density lipoprotein (HDL)-cholesterol (p<0.0001). There was a linear association between waist circumference, waist-to-hip ratio, waist-to-height ratio, BMI and CHD events. The age-adjusted and centre-adjusted relative risks (95% CI) for CHD were 1.57 (1.22 to 2.01), 1.75 (1.34 to 2.87), 2.3 (1.79 to 2.99) and 1.99 (1.54 to 2.56) in the 5th quintile vs the first quintile of waist circumference, waist-to-hip ratio, waist-to-height ratio and BMI distribution, respectively. After further adjustment for school duration, physical activity, tobacco and alcohol consumption, hypertension, diabetes, HDL-cholesterol and triglycerides, the relative risks for CHD were 0.99 (0.76 to 1.30) for waist circumference (p = 0.5), 1.22 (0.93 to 1.60) for waist-to-hip ratio (p = 0.1), 1.53 (1.16 to 2.01) for waist-to-height ratio (p = 0.03) and 1.30 (0.99 to 1.71) for BMI (p = 0.06).

CONCLUSION

In middle-aged European men, waist-to-height ratio identifies coronary risk more strongly than waist circumference, waist-to-hip ratio or BMI, though the difference is marginal.

Depressed mood and dietary fish intake: direct relationship or indirect relationship as a result of diet and lifestyle?

Previous studies have suggested an association between depressed mood and the dietary intake of fish. In all cases, however, dietary fish intake has been considered at the exclusion of all other aspects of the diet. This analysis investigates associations between depressed mood and dietary fish intake, while also concurrently investigating intake of a number of other dietary components. The analysis is conducted on data from 10,602 men from Northern Ireland and France screened for inclusion into the PRIME cohort study. Depressed mood was assessed using a self-report questionnaire based on the Welsh Pure Depression sub-scale of the Minnesota Multiphasic Personality Inventory, diet was assessed using a Food Frequency Questionnaire, and limited demographics were also measured. Using regression, depressed mood is initially inversely associated with dietary fish intake. On inclusion of all other dietary variables, the strength of this relationship reduces but remains, and significant associations with a number of other foods are also found. On additional inclusion of all demographic variables, the strength of the above relationships again reduces, and associations with various measures of socio-economic status and education are also significant. These findings suggest that depressed mood is associated with fish intake both directly, and indirectly as part of a diet that is associated with depression and as part of a lifestyle that is associated with depression. Additional support for these conclusions is also provided in the pattern of associations between depressed mood and diet in the two countries. The relative contributions of fish intake to depressed mood both directly and indirectly are yet to be determined. However, while diet is not measured and until lifestyle can be adequately measured, the potential roles of diet and lifestyle in the association between depressed mood and dietary fish intake should not be ignored.

Type A behaviour and consumption of an atherogenic diet: No association in the PRIME study

It has previously been suggested that the association between Type A behaviour and coronary heart disease (CHD) may be mediated through diet. This analysis investigates associations between Type A behaviour and diet, with particular focus on foods high in saturated fats and cholesterol (cake, cheese, eggs and fried potatoes), foods high in unsaturated fats (fish and nuts), and fruit and vegetables. The analysis was conducted on data collected from 10,602 men from Northern Ireland and France screened for inclusion in the PRIME cohort study. Type A behaviour was measured using the Framingham Type A Behaviour Patterns Questionnaire, diet was measured using a Food Frequency Questionnaire and various demographic details were also assessed. Levels of Type A behaviour and intakes of all food groups were similar to previous studies. Using regression, Type A behaviour was significantly associated with diet, and specifically with a higher consumption of cheese and vegetables in Northern Ireland, and a higher consumption of cake, fish and vegetables in France. These associations are most plausibly explained as a result of lifestyle, although the possibility of independent associations between Type A behaviour and diet remains. The work is limited by the use of questionnaires, but the findings available suggest that Type A behaviour is unlikely to be associated with the consumption of a diet that has previously been linked to CHD. These findings suggest that any association between Type A behaviour and CHD is unlikely to be mediated through diet.

[Coronary mortality in France according to data sources]

BACKGROUND

Since 1985, two sources of information currently yield coronary disease frequency indicators among the French population: the national cause of death statistics set up by the CépiDC (INSERM), on the one hand, and three registries recording myocardial infarction and coronary deaths as defined by the WHO MONICA Project in three regions (Bas-Rhin, Communauté Urbaine de Lille, Haute-Garonne) on the other hand. Particularly, an inquiry for each possibly coronary death allows the registries to conclude positively (with or without a myocardial infarction), negatively or that no conclusion can be drawn because of insufficient data. The aim of the present work is to analyze concordance between coronary deaths issuing from the two sources according to their definition, while taking into account, or not, multiple causes listed on the death certificates.

MATERIAL

and methods: In total, 4,664 deaths occurring in 2000 in the 35-64 year-old population of the three regions identified by the CépiDc were paired with the 812 deaths analyzed by the registries. The MONICA classification was compared with that of the CépiDC which used the ICD 10th Revision of the initial cause or after taking into account multiple causes. In each case, the concordance between the final classifications (coronary deaths or not) and the mortality ratio obtained from the two sources were computed.

RESULTS

and conclusions: Eight hundred and six deaths could be paired: 310 with a coronary cause according to the registries, 420 of presumed coronary cause but with insufficient data and 76 of non coronary origin. Whereas the total number of coronary deaths was similar for the two sources, their concordance was relatively low (kappa=0.61). However, when the deaths with insufficient data were included in the MONICA definition, concordance decreased and a large underestimation (59%) of the coronary mortality is given by the national statistics as compared to the registries. Taking into account multiple causes of death and not only the initial cause permitted partly to reduce this underestimation (42%) and to increase concordance (kappa from 0.46 to 0.51). These findings have important consequences for international comparisons concerning coronary disease. Indeed, the MONICA Project showed that the frequency of deaths with insufficient data was especially elevated in France leading to an underestimation of the coronary death rates provided by the national statistics in comparison with other countries, particularly in Europe.

Contributions of Depressive Mood and Circulating Inflammatory Markers to Coronary Heart Disease in Healthy European Men

Background— Data on the possible association between depressive disorders and inflammatory markers are scarce and inconsistent. We investigated whether subjects with depressive mood had higher levels of a wide range of inflammatory markers involved in coronary heart disease (CHD) incidence and examined the contribution of these inflammatory markers and depressive mood to CHD outcome.

Methods and Results— We built a nested case-referent study within the Prospective Epidemiological Study of Myocardial Infarction (PRIME) study of healthy middle-aged men from Belfast and France. We considered the baseline plasma sample from 335 future cases (angina pectoris, nonfatal myocardial infarction, coronary death) and 670 matched controls (2 controls per case). Depressive mood characterized men whose baseline depression score (13-item modification of the Welsh depression subscale) was in the fourth quartile (mean score, 5.75; range, 4 to 12). On average, men with depressive mood had 46%, 16%, and 10% higher C-reactive protein, interleukin-6, and intercellular adhesion molecule-1 levels, respectively, independently of case-control status, social characteristics, and classic cardiovascular risk factors; no statistical difference was found for fibrinogen. The odds ratios of depressive mood for CHD were 1.35 (95% CI, 1.05 to 1.73) in univariate analysis and 1.50 (95% CI, 1.04 to 2.15) after adjustment for social characteristics and classic cardiovascular risk factors. The latter odds ratio remained unchanged when each inflammatory marker was added separately, and in this analysis, each inflammatory marker contributed significantly to CHD event risk.

Conclusions— These data support an association of depressive mood with inflammatory markers and suggest that depressive mood is related to CHD even after adjustment for these inflammatory markers.

Education, socioeconomic and lifestyle factors, and risk of coronary heart disease: the PRIME Study

BACKGROUND

Socioeconomic differentials have been described in the risk of coronary heart disease (CHD) but the extent to which these differentials are explained by lifestyle factors has been examined to a lesser degree. We have examined the contribution of socio-economic factors to risk of CHD in a large cohort study in France and Northern Ireland.

METHODS

In all, 10 593 men aged 50-59 years were examined between 1991 and 1994 in centres in Northern Ireland, Lille, Strasbourg, and Toulouse. Details were obtained for a number of socio-economic indicators from the men at the baseline examination. Men were also screened for evidence of CHD and followed annually by questionnaire for incident cases of coronary disease. Coronary events (coronary deaths, myocardial infarction, and angina) were documented by clinical records and were reviewed by an independent medical committee.

RESULTS

In all, 842 men (8%) showed some evidence of CHD at screening examination and these men were more likely to be living in poorer material circumstances, be unemployed, or have had less full-time education than men without CHD at screening in both France and Northern Ireland. These relationships persisted following adjustment for all known risk factors for CHD. Among men who were initially free of CHD there were clear socio-economic differentials (years of full-time education, unemployment, and educational level) in the distribution of several risk factors for CHD, notably smoking habit (which differs in France and Northern Ireland), systolic blood pressure, body mass index, and fibrinogen. Total cholesterol in contrast showed no socio-economic differential whilst those with a shorter period of full-time education and the unemployed tended to be high consumers of alcohol. In this cohort of men free of CHD at baseline few socio-economic indicators showed relationships with risk of CHD by 5 years of follow-up. Only years in full education, educational level, and unemployment status when adjusted only for age and country showed significant relationships with CHD risk, but these became non-significant following adjustment for major CHD risk factors.

CONCLUSIONS

Socio-economic differentials in long-term risk of CHD are apparent in both cohorts of men from France and Northern Ireland, particularly in men with evidence of CHD at baseline. Among men free of CHD at baseline, although there is strong evidence of socio-economic differentials in cardiovascular risk factors these do not contribute independently to risk of CHD at 5 years of follow-up in this large cohort of men from France and Northern Ireland.

Physical activity patterns in 50-59 year men in France and Northern Ireland. Associations with socio-economic status and health behaviour

BACKGROUND

This study aimed to compare physical activity patterns and their associations with socio-economic status (SES) and health behaviour in two countries at contrasting risk for coronary heart disease (CHD).

METHODS

This paper is a cross-sectional analysis of 7359 French and 2398 Northern Irish 50-59 year men of the PRIME cohort. Net energy expenditure due to physical activity (PAE) was assessed by means of the MOSPA-Q taking high-intensity recreational activities into account. SES was evaluated by educational attainment and material conditions. Different behavioural factors (smoking, alcohol intake and healthy eating patterns) were considered.

RESULTS

The prevalence of walking or cycling to work was greater in Northern Ireland (p < 10(-5)) whereas leisure PAE (p < 10(-5)) and high-intensity leisure-time activity (p < 10(-5)) were higher in France. Education was positively associated with leisure-time PAE in Northern Ireland but negatively in France. However education in both countries and material conditions in France were favourably associated with the regular practice of high-intensity recreational activities. Alcohol consumption was positively associated with leisure PAE in France only (p < 10(-3)). A weak negative association was also observed between smoking and leisure-time activities while healthy eating patterns were associated with greater physical activity in both countries.

CONCLUSIONS

Physical activity patterns and their relationships with SES and alcohol consumption differ in France and in Northern Ireland. Our results underline the need to focus on low socio-economic groups for health promotion but, also, to adapt strategies to promote physical activity according to cultural differences between countries. Our results also show that healthy behaviours tend to cluster in middle-aged men.

Change in cardiovascular risk factors in France, 1985–1997

The change in the main cardiovascular risk factors in France was assessed using the MONICA population surveys conducted in the Urban Community of Lille, Bas-Rhin and Haute-Garonne. Trends in obesity, tobacco smoking, hypertension, hypercholesterolaemia and self-reported diabetes were established for the first (1985-1988) and the last (1995-1997) survey. The results indicate that the prevalence of overweight and obesity remained stable in both genders; tobacco smoking decreased in men but increased in women. Prevalence of hypertension decreased, and preventive measures improved in both genders. Prevalence of hypercholesterolaemia remained stable, and preventive measures improved only in men. Prevalence of self-reported diabetes increased solely in women, and preventive measures improved in both genders. However, in 1995-1997 still 40% of the treated hypertensive and 30% of the treated hypercholesterolaemic subjects were not adequately controlled. We conclude that prevalence and prevention of the main cardiovascular risk factors have evolved favourably in France, but the management of hypercholesterolaemia and hypertension can still be improved.

Psychosocial risk factors for heart disease in France and Northern Ireland: the Prospective Epidemiological Study of Myocardial Infarction (PRIME)

BACKGROUND

France has a substantially lower level of premature mortality from cardiovascular diseases (CVD) relative to its comparators. Compared with Northern Ireland, France has one-half the rate, despite having a similar cardiovascular risk profile to Northern Ireland. In this prospective longitudinal study the psychosocial risk hypothesis for CVD was tested.

METHOD

A cohort of 9758 men (7359 in France and 2399 in Northern Ireland) aged 50-59 years who were initially free of any CVD were recruited. At baseline the subjects completed a psychosocial questionnaire, measuring hostility, depression, social support, and the Type A behaviour pattern. At 5-years follow-up their clinical status was determined.

RESULTS

Multivariate analysis indicated that, contrary to prediction, France had a substantially more negative psychosocial risk profile than Northern Ireland. The psychosocial risk factors were not successful at predicting at 5-years follow-up the hard clinical endpoint of definite fatal/non-fatal myocardial infarction. In the case of the softer clinical endpoint, angina pectoris/unstable angina, only depression predicted outcome with a small effect size.

CONCLUSION

The findings provide little support for the psychosocial risk hypothesis. The psychosocial risk profile was more negative in France, the opposite of that predicted. The finding of a relationship between depression and angina may reflect a tendency for individuals who respond negatively on mood state to report more cardiac symptoms irrespective of physical disease state.

Five-year incidence of angina pectoris and other forms of coronary heart disease in healthy men aged 50-59 in France and Northern Ireland: the Prospective Epidemiological Study of Myocardial Infarction (PRIME) Study

BACKGROUND

The North-South gradient in myocardial infarction and coronary death rates in various western European regions has been described by the WHO MONICA Project over the last decade. The results of the 5-year follow-up of the Prospective Epidemiological Study of Myocardial Infarction (PRIME) Study reported here give the opportunity of extending the comparison to the incidence of angina pectoris in men aged 50-59 living in four regions (Belfast, Lille, Strasbourg, Toulouse) which were covered by the MONICA Project.

METHODS

The PRIME Study is a multicentre cohort study with a common protocol and centralized event analysis. It included 10 600 men, of whom 9758 (7359 in France and 2399 in Belfast) were free of coronary disease at entry with 842 (496 in France and 346 in Belfast) having pre-existing coronary disease.

RESULTS

In France, subjects free of coronary heart disease at baseline developed 106 cases of myocardial infarction or coronary death (2.93/1000 subjects per year) and 94 cases of angina pectoris (2.61/1000). In Belfast, 61 developed myocardial infarction or coronary death (5.24/1000) and 60 angina pectoris (5.39/1000). Hazard rate ratios for Belfast in comparison to France were respectively 1.79 (95% CI : 1.30-2.47) and 2.07 (1.49-2.86) for each class of clinical complication.

CONCLUSION

Rate ratios for angina pectoris incidence between Northern Ireland and France in the PRIME Study are comparable to those for myocardial infarction or coronary death reported by the WHO MONICA Project and suggest that the North-South gradient in Europe applies to different manifestations of coronary disease.

Relationships between alcoholic beverages and cardiovascular risk factor levels in middle-aged men, the PRIME Study. Prospective Epidemiological Study of Myocardial Infarction Study

The relationships between alcoholic beverages and cardiovascular risk factors were assessed in 6730 men living in France or Northern Ireland. In France, all alcoholic beverages were significantly correlated with body mass index (BMI), systolic (SBP) and diastolic blood pressure (DBP), high density lipoprotein (HDL) parameters, PAI-1 and Factor VII, whereas only wine was negatively related with fibrinogen levels. After adjusting for center, age, BMI, educational level, smoking and marital status, wine had a lesser effect on blood pressure, triglyceride, apo B and LpE:B levels than beer. Wine was associated with lower fibrinogen levels and beer with higher PAI-1 activity levels independent of the amount of alcohol consumed. In Northern Ireland, wine was negatively correlated with BMI, triglycerides, LpE:B and fibrinogen, whereas beer was positively correlated with SBP and DBP, triglycerides, HDL, apoprotein A-I and fibrinogen. Multivariate analysis showed wine to be positively associated with HDL parameters, and negatively with fibrinogen levels. Wine was also associated with higher LpA-I levels and lower fibrinogen levels independent of the amount of alcohol consumed. We conclude that alcohol consumption is related to lipid, lipoprotein and haemostatic variables, but the magnitude of the relationships depends on the type of alcoholic beverage. Also, some effects might be related to non-alcoholic components.

Leisure-time physical activity and regular walking or cycling to work are associated with adiposity and 5 y weight gain in middle-aged men: the PRIME Study

OBJECTIVE

To examine the influence of physical activity on body mass index (BMI), waist circumference (W) and body mass changes (DeltaBMI) in middle-aged men, with special regard to moderate-intensity activities.

DESIGN

Longitudinal study of adults who participated in the PRIME Study.

SUBJECTS

A cohort of 8865 men aged 50-59 y, free of coronary heart disease.

MEASUREMENTS

BMI and W at baseline, body mass changes over a 5 y period. Detailed baseline assessment of net energy expenditure due to physical activity (PAE) in the preceding year, according to category of activity, by means of the MOSPA Questionnaire. PAE was expressed in weekly metabolic equivalent scores (MET h/week).

RESULTS

After adjustment for confounders, the multiple regression analyses indicated that BMI, W and DeltaBMI were inversely associated with PAE spent in getting to work (P<10(-5), <10(-5) and 0.04, respectively) and practice of high-intensity (>or=6 MET) recreational activities (<0.01, <10(-5) and <0.01). Men who regularly spent more than 10 MET h/week in walking or cycling to work had a mean BMI, W and DeltaBMI respectively 0.3 kg/m(2), 1 cm and 0.06 kg/m(2) lower than those who did not expend energy in getting to work. In the subgroup of subjects who did not perform high-intensity activities, the level of recreational PAE was inversely associated with BMI and W but not with subsequent weight-gain.

CONCLUSION

These findings indicate that, in middle-aged men, physical activities of moderate-intensity, which are probably easier to promote than more vigorous activities and, in particular, a more current daily activity, walking or cycling to work, may have a favourable effect on body fat markers and body mass gain.

Association of hypertensive status and its drug treatment with lipid and haemostatic factors in middle-aged men: the PRIME study

AIMS

To assess the association of hypertensive status and antihypertensive drug treatment with lipid and haemostatic levels in middle-aged men.

METHODS AND RESULTS

Hypertensive status, antihypertensive drug treatment, total and high-density lipoprotein (HDL) cholesterol, triglyceride, apoproteins A-I and B, lipoparticles LpA-I, LpE:B and Lp(a), fibrinogen, plasminogen activator inhibitor-1 (PAI-1) activity and factor VII were assessed in a sample of men 50-59 years living in France (n = 7050) and Northern Ireland (n = 2374). After adjustment for age, body mass index, smoking status, educational level, country, alcohol drinking and hypolipidaemic drug treatment, untreated hypertensive subjects had higher levels of total cholesterol, triglyceride, apoproteins A-I and B and PAI-I activity than normotensive subjects. On univariate analysis, diuretics decreased total and HDL-cholesterol and apoproteins A-I and B; those differences remained after multivariate adjustment. Treatment with beta-blockers decreased total and HDL-cholesterol, apoprotein A-I and LpA-I, and this effect remained after multivariate adjustment. Calcium channel blockers decreased total cholesterol and apoproteins A-I and B; those differences remained significant after multivariate adjustment. ACE inhibitors decreased total cholesterol, triglycerides, apoprotein B and LpE:B; and this effect remained after multivariate adjustment. Analysis of the subjects on monotherapy showed beta-blockers to decrease total cholesterol and HDL parameters and angiotensin-converting enzyme (ACE) inhibitors to decrease low-density lipoprotein (LDL)-related parameters, while no effect was found for the other antihypertensive drugs.

CONCLUSIONS

Hypertensive status is associated with an unfavourable lipid and haemostatic profile in middle-aged men. Antihypertensive treatment with beta-blockers decreases HDL parameters, whereas treatment with ACE inhibitors appears to decrease total cholesterol and LDL-related parameters.

Characteristics of male vitamin supplement users aged 50-59 years in France and Northern Ireland: the PRIME Study. Prospective Epidemiological Study of Myocardial Infarction

The prevalence and characteristics of vitamin supplement users were assessed in 7538 male subjects aged 50-59 from France and 2468 from Northern Ireland. In France, 15% of subjects used vitamin supplements; users were significantly younger, had a lower body mass index, a higher educational level, had more frequently a hard physical job, reported more frequently a personal history of disease and were less frequently retired or inactive than non-users. In Northern Ireland, 21% of subjects were vitamin supplement users; users had a lower body mass index, drank less alcohol, had a higher educational level, were more frequently non-smokers and professionally active, and reported a hard physical job and the practice of leisure sports more frequently than non-users. Finally, vitamin supplement users in Northern Ireland had a lower consumption of alcohol, smoked less, had a lower frequency of personal history of disease and were more frequently on dietary therapy for hypertension or dyslipidaemia than their French counterparts. We conclude that vitamin supplement use is associated with a healthier lifestyle and with dietary measures against hypertension and dyslipidaemia in Northern Ireland. The less favorable lifestyle observed for vitamin supplement users in France awaits further investigation.

Overweight and obesity: a major challenge for coronary heart disease secondary prevention in clinical practice in Europe

AIMS

To evaluate the management of overweight and obesity in coronary artery disease patients in Europe.

METHODS AND RESULTS

The EUROASPIRE Study is a multicentre epidemiological study involving nine European countries. The major cardiovascular risk factors and their management were collected from hospital records and measured at least 6 months after hospitalization during a specific interview. A total of 4863 consecutive records from men and women with coronary artery disease, under 71 years of age, were reviewed. Interviews were obtained for 3569 (73%). Body mass index was computed from height and weight noted in the medical records and measured at interview. Management of overweight and obesity was recorded at interview. At least 6 months after hospitalization, 75% of women and 80% of men were overweight and 33% of women and 23% of men were obese. Height noted in medical records was over-estimated, inducing an under-estimation of obesity in 16% of men and 33% of women. Advice from a nutritionist was offered in less than 20% of obese patients. The same trends were observed in all participating countries.

CONCLUSIONS

Prevalences of overweight and obesity are high in coronary artery disease patients in Europe. A systematic measurement of height and weight is a prerequisite to a better management of this common modifiable risk factor.

Patterns of alcohol consumption in middle-aged men from France and Northern Ireland. The PRIME study

OBJECTIVE

To assess the patterns of alcohol consumption in France and Northern Ireland.

DESIGN

Four cross-sectional studies.

SETTING

Sample of 50-59 y old men living in France and Northern Ireland, consuming at least one unit of alcoholic beverage per week.

SUBJECTS

5363 subjects from France and 1367 from Northern Ireland.

INTERVENTIONS

None.

RESULTS

Consumption of wine was higher in France whereas consumption of beer and spirits was higher in Northern Ireland. Alcohol drinking was rather homogeneous throughout the week in France, whereas Fridays and Saturdays accounted for 60% of total alcohol consumption in Northern Ireland. In both countries, current smokers had a higher consumption of all types of alcoholic beverages than non-smokers. Similarly, obese and hypertensive subjects had a higher total alcohol consumption than non-obese or normotensive subjects, but the type of alcoholic beverages differed between countries. In Northern Ireland, subjects which reported some physical activity consumed significantly less alcoholic beverages than sedentary subjects, whereas no differences were found in France. Conversely, subjects with dyslipidemia consumed more alcoholic beverages than normolipidemic subjects in France, whereas no differences were found in Northern Ireland. In France, total alcohol, wine and beer consumption was negatively related to socioeconomic status and educational level. In Northern Ireland, total alcohol, beer and spirits consumption was negatively related whereas wine consumption was positively related to socioeconomic status and educational level.

CONCLUSIONS

Alcohol drinking patterns differ between France and Northern Ireland, and also according to cardiovascular risk factors, socioeconomic and educational levels.

SPONSORSHIP

Merck, Sharp & Dohme-Chibret (France), the NICHSA and the Department of Health and Social Service (Northern Ireland).

Trends and geographical disparities in coronary heart disease in France: are results concordant when different definitions of events are used?

OBJECTIVES

To assess whether different definitions of acute coronary events yielded concordant results concerning trends and geographical disparities in coronary heart disease (CHD) mortality and morbidity in France.

STUDY DESIGN

Data from three French CHD registries participating in the WHO MONICA Project during the period 1985-1992.

SETTING

Three areas of about one million inhabitants each in the North, South and East of France.

SUBJECTS

About 2,000 acute coronary events each year.

MAIN OUTCOME MEASURES

Mortality, annual rate of fatal and non-fatal events, incidence of first and recurrent events, case-fatality rates.

RESULTS

For incidence and mortality, the broader the broader the definition of the acute event, the higher the reported rates. The same tendency was not observed for case-fatality rates. Comparing between-registry rates for mortality, 28-day case-fatality and hospital case fatality yielded relatively concordant results whatever the definition of event. As a whole, the higher mortality rate in Lille and its intermediate rank in Strasbourg were related more to disparities in case-fatality rates, with only small variations in incidence rates, independently of the definition used. Comparing temporal trends in rates within and between regions, a consistent decrease in annual mortality rates and case-fatality rates was observed, whatever the definition. In contrast, the incidence of non-fatal probable myocardial infarction did not change during the period in any register.

CONCLUSIONS

Although the absolute estimates of rates were variable with the definition of the event, major findings in relation to trends and geographical disparities were fairly consistent across the definitions: the North-South gradient in mortality observed in France was found to be much more pronounced for case fatality than for incidence. The proportion of milder acute myocardial infarction is currently increasing and this element should be taken into account when analysing CHD rates.

Unhealthy effects of atmospheric temperature and pressure on the occurrence of myocardial infarction and coronary deaths. A 10-year survey: the Lille-World Health Organization MONICA project (Monitoring trends and determinants in cardiovascular disease)

BACKGROUND

Associations between an increase in coronary heart disease occurrence and low atmospheric temperatures have been reported from mortality data and hospital admission registries. However, concomitant increases in noncardiovascular case fatality rates and selection bias of hospital cases may weaken this observation. In this study, we addressed the question of the relationships between fatal and nonfatal coronary diseases and meteorological variables in 10-year data (1985 to 1994) collected in a morbidity registry (Lille-WHO MONICA Project) monitoring 257 000 men from 25 to 64 years of age.

METHODS AND RESULTS

The impacts of atmospheric temperature (in Celsius) and pressure (in millibars) on daily rates of myocardial infarction (MI) and coronary deaths were studied. Percentages of variation of event rates according to meteorological variations were derived from the relative risks estimated with a Poisson regression model. During the 10-year longitudinal survey, 3616 events occurred. Rates of events decreased linearly with increasing atmospheric temperature. For atmospheric pressure, we detected a V-shaped relationship, with a minimum of daily event rates at 1016 mbar. A 10 degrees C decrease was associated with a 13% increase in event rates (P<0.0001); a 10-mbar decrease <1016 mbar and a 10-mbar increase >1016 mbar were associated with a 12% increase (P=0.001) and an 11% increase (P=0. 01) in event rates, respectively. These effects were independent and influenced both coronary morbidity and mortality rates, with stronger effects in older age groups and for recurrent events.

CONCLUSIONS

This longitudinal study is the first to estimate the attributable effect of meteorological variables on MI morbidity in population and strongly argues for a systematic fight against cold in cardiovascular disease prevention, particularly in older ages and after a first MI.

[Management of risk factors after coronary heart disease in European countries]

BACKGROUND

Despite clinical and epidemiological evidence of benefits from sustained management of vascular risk factors following coronary heart disease, the implication of physicians in secondary prevention remains limited. In 1994, several European scientific societies published jointly guidelines for the prevention of coronary heart disease in clinical practice, ranking as the highest priority the reduction of risk factors in coronary patients.

METHODS

The European Society of Cardiology launched at the same period a study on the prevalence and management of vascular risk factors of coronary patients in Europe, the EUROASPIRE project. Six months after a coronary event 3,569 patients, from a total population of 4,863 affected individuals recruited in hospitals of 9 European countries, were interviewed and examined to estimate the levels and management of their vascular risk factors.

RESULTS

At least six months after discharge, one patient out of five kept on smoking, one out of four was still obese, one out of two had high blood pressure levels and 44% total cholesterolemia over 5.5 mmol/L. More than 8 smoking patients out of 10 attempted to stop smoking and 8 obese patients out of 10 attempted to lose weight. More than 40% of patients, treated or not for hypertension, had systolic blood pressure levels over 140 mm Hg, and almost one patient out of two, treated or not treated for dyslipemia, a total cholesterolemia over 5.5 mmol/L.

CONCLUSIONS

Given the high prevalence of vascular risk factors in coronary patients, efficient secondary prevention aiming at the reduction of the levels of these risk factors, may have a major impact on the decrease of morbidity and mortality of these patients. Thus, joined European efforts to elaborate, diffuse and evaluate secondary prevention strategies towards physicians and patients should be rapidly developed to facilitate the achievement of such benefits for coronary patient health.

Is hospital care involved in inequalities in coronary heart disease mortality? Results from the French WHO-MONICA Project in men aged 30-64

OBJECTIVES

The goal of the study was to assess whether possible disparities in coronary heart disease (CHD) management between occupational categories (OC) in men might be observed and contribute to the increasing inequalities in CHD morbidity and mortality reported in France.

METHODS

The data from the three registers of the French MONICA Collaborative Centres (MCC-Lille, MCC-Strasbourg, and MCC-Toulouse) were analysed during two period: 1985-87 and 1989-91. Acute myocardial infarctions and coronary deaths concerning men, aged 30-64 years, were included. Non-professionally active and retired men were excluded. Results were adjusted for age and MCC, using a logistic regression analysis.

RESULTS

605 and 695 events were analysed for 1985-87 and 1989-91, respectively. Out of hospital cardiac arrests, with or without cardiac resuscitation, and 28 day case fatality rates were lower among upper executives in both periods. A coronarography before the acute event had been performed more frequently in men of this category and the proportion of events that could be hospitalised was higher among them. In both periods, the management of acute myocardial infarctions in hospital and prescriptions on discharge were similar among occupational categories.

CONCLUSIONS

For patients who could be admitted to hospital, the management was found to be similar among OCs, as was the 28 day case fatality rate among the hospitalised patients. In contrast, lower prognosis and higher probability of being hospitalised after the event among some categories suggest that pre-hospital care and the patient's conditions before the event are the primary factors involved.

[Secondary prevention of coronary disease in France. Result of the EUROASPIRE study: the Lille register of ischemic cardiopathies]

The EUROASPIRE study was initiated to assess the impact of recommendations concerning secondary prevention of coronary artery disease in Europe published in 1994 by the European Societies of Cardiology, Hypertension and Atherosclerosis. France and eight other countries are involved in this project. The authors report the French data. A total of 546 men and women, aged less than 71, divided into 4 diagnostic groups (coronary bypass, angioplasty, myocardial infarction, acute ischaemia) were selected in different departments of cardiology. Data concerning their main risk factors and management were noted from the hospital files. At least 6 months after their hospital admission, 396 patients were systematically interrogated and examined. The availability of information on the risk factors in the hospital files varied according to the risk factor and diagnostic group from 61 to 97%. At the time of hospital admission, 42% of patients were considered to be smokers and 23% to be obese. Six months after hospital admission, 28% of patients were still smoking, 34% were obese, 49% had total cholesterol levels greater than 5.5 mmol/L (2.10 g/L) and 48% had blood pressure readings of over 140/90 mmHg. In France, as in other European countries, the prevalence of modulable risk factors of coronary artery disease is high at least 6 months after hospital admission. Systematic application of the recommendations of scientific societies should result in a significant decrease in recurrences and in mortality after an initial coronary event.

[Epidemiology of sudden coronary death in France (1985-1982)]

The physiopathology of sudden coronary death (SCD) is well known. However, its impact on the population of France has not been studied in depth. The MONICA project recenses all coronary events in subjects of 25 to 64 years of age in a given geographic area. The definition of SCD is coronary death occurring less than one hour after the onset of symptoms. Out of 4,004 coronary deaths recorded from 1985 to 1992 in the Bas-Rhin and Haute-Garonne departments, 48% in men and 43% in women were SCD. This event occurred outside hospital in 89% of men and 85% of women. SCD was the first ischaemic symptom in 61% of SCD in men and in 74% of women. Of the SCD occurring outside hospital, 2 to 6% of men and 6 to 7% of women. received emergency treatment in less than 5 minutes. The frequency of SCD increased with age and was highest in men. Between 1985 and 1992, standardised rates (35-64 years) in men fell from 62 to 48/100,000 in the Bas-Rhin (p < 0.01) and from 59 to 36/100,000 in the Haute-Garonne (p < 0.0001); in women, the frequency fell from 17 to 8/100,000 in the Bas-Rhin (p < 0.01) and remained stable in the Haute-Garonne (10/100,000 to 11/100,000). In conclusion, for the first time in France, accurate epidemiological data on SCD is presented, underlying its importance in terms of public health.

Incidence, case fatality, risk factors of acute coronary heart disease and occupational categories in men aged 30-59 in France

OBJECTIVES

To assess the incidence and case fatality rate (CFR) from acute coronary insufficiency in men among occupational categories and to analyse the relationship between these disparities and the distribution of cardiovascular risk factors in the French population.

SETTING

Three registers of the WHO-MONICA project in France: the urban area of Lille and two French districts: Bas-Rhin and Haute-Garonne.

METHODS

Two sets of data were used: 1) the incident cases collected by the three MONICA Collaborating Centres (MCC) of the French WHO-MONICA Project (Lille, Strasbourg and Toulouse), between 1985 and 1989; 2) a cross-sectional study on cardiovascular risk factor prevalence performed in 1985-1989 in the three areas corresponding to the MCC.

SUBJECTS

The data concern 5133 new coronary events in men aged 30-59 and a sample of 1863 men aged 30-59.

RESULTS

A strong relationship was observed between occupational categories and the incidence of acute myocardial infarction and coronary events as well as CFR. Both incidence and CFR were lower among senior executives. Incidence was higher among employees and workers. However, employees, as opposed to unskilled workers, did not have higher CFR. Using occupational category as a statistical unit, the incidence of first acute myocardial infarction and coronary events was associated with the prevalence of smokers in the population (r = 0.50, P = 0.06 and r = 0.61, P = 0.02). The CFR was associated with systolic blood pressure (r = 0.82, P = 0.002), and the prevalence of smokers (r = 0.65, P = 0.02). None of the measures of incidence or case fatality among categories was related to cholesterol, HDL-cholesterol or body mass index.

CONCLUSIONS

Strong differences were observed between occupational categories and the incidence of acute myocardial infarction, coronary events and CFR. These differences were found to be closely related to the social distribution of two major cardiovascular risk factors: tobacco smoking and blood pressure.