Lifestyle habits and mortality from all and specific causes of death: 40-year follow-up in the Italian Rural Areas of the Seven Countries Study

OBJECTIVES

Three lifestyle factors were investigated in a population study to explore their relationships with a long-term mortality.

MATERIAL AND METHODS

In a cohort of 1564 men aged 45-64 and examined in 1965 within the Italian Rural Areas of the Seven Countries Study, smoking habits, physical activity at work and eating habits (as derived from factor analysis) were determined. During the follow-up 693 men died in 20 years and 1441 in 40 years.

RESULTS

In Cox proportional hazards models men smoking cigarettes (versus never smokers), those having a sedentary activity (versus the very active) and those following the Diet Score 1, indexing an unhealthy Diet (versus men with a Diet close to the healthy Mediterranean style) had highly significant hazards ratios (HR) in relations with 20- and 40-year mortality from all causes, coronary heart disease (CHD), cardiovascular disease (CVD) and cancer. HR for all causes in 40 years were 1.44 (95% confidence intervals, CI, 1.27 and 1.64) for smokers, 1.43 (CI 1.23 and 1.67) for sedentary people, and 1.31 (CI 1.15 and 1.50) for men with unhealthy diet. Larger HR were found for CHD, CVD and cancers deaths. Combination of 3 unhealthy risk factors versus their absence was associated with 4.8-year life loss in the 20-year follow-up and 10.7-year in the 40-year follow-up.

CONCLUSIONS

Lifestyle behavior linked to physical activity and smoking and eating habits is strongly associated with mortality and survival in middle aged men during long-term follow-up.

Cardiovascular risk factors predict survival in middle-aged men during 50 years

OBJECTIVES

We aimed at studying the expectancy of life in middle-aged men as a function of several personal characteristics and risk factors.

MATERIAL AND METHODS

A sample of 1712 Italian men aged 40-59, first examined in 1960, was followed-up for mortality for 50 years. The length of survival was estimated as a function of 48 personal characteristics and risk factors using the multiple linear regression.

RESULTS

In 50 years 1672 men died (97.7%) and 40 survived (2.3%). Twenty risk factors, most of which were never measured in previous studies of such duration, proved to be significant, for the estimation of survival with an overall adjusted R(2) of 0.3236. They were: age, 4 anthropometric measurements (body mass index, and its squared term, laterality-linearity index, shoulder/pelvis shape), mean blood pressure, father and mother history of premature (<65-year) death, marital status, arm circumference, 2 respiratory measurements (vital capacity and forced expiratory volume), serum cholesterol, corneal arcus, xantelasma, cancer, cardiovascular diseases, diabetes and chronic bronchitis. Coefficients of 5 suitable risk factors became definitely larger after adjustment for regression dilution bias with 5 year data. All 40 cases of survival were located in the higher 5 deciles of estimated survival and 25 (62.5%) were in the upper decile.

CONCLUSION

A small number of risk factors and personal characteristics, mainly known as cardiovascular risk factors and measured once in middle-aged men, are strongly associated with the length of survival in a 50-year follow-up.

The role of HDL cholesterol in metabolic syndrome predicting cardiovascular events. The Gubbio population study

BACKGROUND AND AIMS

Metabolic syndrome (MS) has recently been claimed to be an important new risk factor for the occurrence of coronary heart disease (CHD) and cardiovascular disease (CVD) events, although it is simply a combination of known risk factors used in a dichotomized fashion. The aims of this analysis were to explore the predictive role of MS for CHD and CVD events in a population study, in comparison with using the same factors in a continuous fashion, with special emphasis on HDL cholesterol.

METHODS AND RESULTS

In the second examination of the Gubbio population study from central Italy, 2650 cardiovascular disease-free men and women, aged 35-74 years around 1990, were examined and followed-up for 12 years. The classic risk factors (sex, age, systolic blood pressure, serum cholesterol and smoking habits) were studied as predictors of CHD and CVD events, alone and with the contribution of other factors (HDL cholesterol, blood glucose, serum triglycerides and waist circumference) included in the so-called MS, based on several multivariate models. MS was also tested after adjustment for other risk factors. MS produced a predictive significant relative risk of 1.67 for CHD events and 1.82 for CVD events, but considering its single risk factors, the only ones contributing to prediction were HDL cholesterol and systolic blood pressure. Dedicated analyses showed that MS does not add anything to the power of prediction beyond the role of the single risk factors treated in a continuous fashion, while the best predictive power is obtained using classic risk factors (sex, age, smoking habits, total cholesterol, systolic blood pressure) with the addition of HDL cholesterol.

CONCLUSIONS

The predictive power of MS is bound only to the presence of HDL cholesterol and blood pressure and does not add anything to using the same risk factor treated in a continuous fashion.

Survey of cardiovascular risk factors in overweight and obese patients (SCOOP study) six-month changes in risk factor levels and cardiovascular risk

BACKGROUND

Obesity is considered a major threat to health worldwide, and its treatment is difficult. The SCOOP project is aimed at describing the effects of treating obesity in everyday clinical practice, following a standard protocol of weight reduction.

METHODS

A total of 2472 obese or overweight men and women (with a body mass index of 27 units or more), aged between 35 and 74, were enrolled in different clinical facilities. Treatment included a 25% average reduction in caloric intake and a recommendation to take a brisk walk for at least 150 min per week. After 6 months, a second survey was then carried out.

RESULTS

At the entry examination, patients exhibited high levels of most cardiovascular risk factors and estimated cardiovascular risks, and a high prevalence of cardiovascular diseases (14.1% in men; 6.3% in women), diabetes (30.5% in men; 25.2% in women) and metabolic syndrome (25.6% in men; 22.8% in women). After 6 months, 69% of all enrolled patients reported for a final examination. Levels of all cardiovascular risk factors were significantly reduced, including estimated cardiovascular risks (-20.4% in men and -12.6% in women). A targeted 10% reduction in body weight was achieved by 19% of patients. Changes in weight and cardiovascular risk factors were highly correlated with the self-reported compliance to prescriptions, and graded with the observed weight reduction. Benefits should be lowered by 30% if it is assumed that the patients who did not show up at the follow-up did not change their characteristics.

CONCLUSION

Short term positive effects of treatment of obesity can be obtained in everyday clinical practice using a simple protocol.

Forty-year coronary mortality trends and changes in major risk factors in the first 10 years of follow-up in the seven countries study

Time trends in coronary heart disease (CHD) mortality during a 40-year follow-up were studied in the Seven Countries Study. Thirteen cohorts of men aged 40-59 at entry were enrolled in seven countries (USA, Finland, the Netherlands, Italy, Serbia, Greece and Japan) for a total of 10,628 subjects. Cardiovascular risk factors were measured at entry and at the 10-year follow-up examination and coronary heart disease mortality data collected during 40 years. During the 40-year follow-up, the hazard rate of the Weibull parametric distribution (annual conditional risk of death) for CHD mortality tended to slightly decline in the US, Finnish, Dutch and Japanese cohorts, moderately increased in Italy and exponentially increased in cohorts of Serbia and Greece. A strong positive association was found between the shape of the hazard curve, describing the acceleration of the hazard, and a score of population mean risk factor changes (serum cholesterol, systolic blood pressure and smoking prevalence) observed during the first 10 years of follow-up, with a correlation coefficient of 0.91 between the two indicators. The countries with a relative decline in the annual hazard function were the same where, during the same historical period, large decreases in official death rate from CHD were recorded, and viceversa. The acceleration in mortality risk for CHD mortality in different countries, described by the shape of the Weibull distribution, is related to changes in mean levels of major coronary risk factors.

Effects of past and recent blood pressure and cholesterol level on coronary heart disease and stroke mortality, accounting for measurement error

The authors aimed to quantify the effects of current systolic blood pressure (SBP) and serum total cholesterol on the risk of mortality in comparison with SBP or serum cholesterol 25 years previously, taking measurement error into account. The authors reanalyzed 35-year follow-up data on mortality due to coronary heart disease and stroke among subjects aged 65 years or more from nine cohorts of the Seven Countries Study. The two-step method of Tsiatis et al. (J Am Stat Assoc 1995;90:27-37) was used to adjust for regression dilution bias, and results were compared with those obtained using more commonly applied methods of adjustment for regression dilution bias. It was found that the commonly used univariate adjustment for regression dilution bias overestimates the effects of both SBP and cholesterol compared with multivariate methods. Also, the two-step method makes better use of the information available, resulting in smaller confidence intervals. Results comparing recent and past exposure indicated that past SBP is more important than recent SBP in terms of its effect on coronary heart disease mortality, while both recent and past values seem to be important for effects of cholesterol on coronary heart disease mortality and effects of SBP on stroke mortality. Associations between serum cholesterol concentration and risk of stroke mortality are weak.

Determinants of longevity and all-cause mortality among middle-aged men. Role of 48 personal characteristics in a 40-year follow-up of Italian Rural Areas in the Seven Countries Study

BACKGROUND AND AIMS

Forty-year all-cause mortality and its association with entry risk factor levels are reported for men enrolled in the Italian Rural Areas of the Seven Countries Study of Cardiovascular Diseases.

METHODS

Forty-eight potential risk factors were measured in 1712 men aged 40-59 at entry examination in 1960. Mortality data were collected during 40 years of follow-up. The relationship of entry risk factor levels with all-cause mortality was studied by univariate and multivariate approaches.

RESULTS

Overall death rate was 83.7%. The main causes of death were cardiovascular diseases, followed by cancer and others. The 48 risk factors were tested with univariate and multivariate approaches. In the final model, 15 risk factors were strongly and significantly related to all-cause mortality and survival. They were age, father and mother history of premature mortality, cigarette smoking, job-related physical activity (protective), body mass index (BMI) (in an inverse J-shaped fashion), mid-arm circumference (protective), mean blood pressure, forced respiratory volume in 3/4 seconds (protective), serum cholesterol, corneal arcus, xanthelasma, presence of cardiovascular diseases, cancer and diabetes at entry examination.

CONCLUSIONS

During a 40-year period 15 mainly cardiovascular risk factors were highly predictive of all-cause mortality and survival in middle-aged men.

Short and long term association of a single serum cholesterol measurement in middle-aged men in prediction of fatal coronary and other cardiovascular events: a cross-cultural comparison through Europe

AIMS

The purpose was to study the association of a single serum cholesterol measurement with early and late coronary and other cardiovascular deaths during 35 years of follow-up in samples of men aged 40-59 years in five European countries.

METHODS AND RESULTS

A single serum total cholesterol measurement was considered in samples from Finland (N = 1563), the Netherlands (N = 811), Italy (N = 1642), Serbia (N = 1537) and Greece (N = 1158) (total = 6711). Seven partitioned proportional hazards models were solved, one for each of seven independent 5-year blocks, to predict coronary, stroke, cardiovascular disease and all-cause mortality risk. Partitioned hazard scores were cumulated. The resulting curves showed a relatively constant strength in risk for coronary deaths as a function of baseline serum cholesterol levels, although a strong relationship during the first 10-year period was followed by a weaker relationship later on. The pooled estimates for the five countries gave a relative risk for 1 mmol/l of serum cholesterol (95% confidence intervals) of 1.44 (1.23-1.68) for the first period; 1.52 (1.31-1.76) for the second period; and 1.16 (1.02-1.32) for the third period; 1.18 (1.05-1.32) for the forth period; 1.17 (1.05-1.31) for the fifth period; 1.22 (1.10-1.35) for the sixth period; 1.18 (1.05-1.32) for the seventh 5-year period of follow-up. No significant relationship were found between serum cholesterol and stroke and all-cause mortality, while intermediate findings were obtained for cardiovascular diseases.

CONCLUSION

A single serum cholesterol measurement in middle aged-men maintains a strong relationship with the occurrence of coronary heart disease (CHD) deaths during 35 years of follow-up.

The relationship of age, blood pressure, serum cholesterol and smoking habits with the risk of typical and atypical coronary heart disease death in the European cohorts of the Seven Countries Study

OBJECTIVE

To explore whether "typical" coronary heart disease (CHD) such as fatal myocardial infarction and sudden death relate to major cardiovascular risk factors in the same way as the "atypical" CHD, such as fatal heart failure and chronic arrhythmias.

DESIGN AND SETTING

Ten cohorts (6633 cardiovascular disease-free men, aged 40-59) in five European countries were examined, age and three major risk factors were measured (systolic blood pressure, serum cholesterol, and smoking habits) and 35-year mortality data were collected. Proportional hazard models were solved with typical and atypical CHD deaths treated separately.

RESULTS

Death rates from typical and atypical CHD were inversely related among the five countries. Mean age at death was significantly higher for atypical than typical (75.8 versus 71.6 years; p < 0.001). In the multivariate analysis conducted on pools of 5 countries (adjusted for countries), the relationship of risk factors with typical CHD was direct and significant for age (hazard ratio-HR-for 5 years of age 1.44 (95% CI 1.36-1.52)), systolic blood pressure (HR for 20 mm Hg, 1.39 (95% CI 1.32-1.47)), serum cholesterol (HR for 1 mmol/l of 1.22 (95% CI 1.16-1.27)) and smoking habits (HR smokers versus non-smokers of 1.39 (95% CI 1.24-1.57)). For atypical CHD, age had a larger HR of 2.27 (95% CI 2.05-2.52), systolic blood pressure had a smaller HR of 1.28 (95% CI 1.16-1.41), serum cholesterol had an inverse non-significant HR of 0.90 (0.58-1.58) and smoking habits had a larger HR of 1.54 (95% CI 1.26-1.89).

CONCLUSIONS

Age and serum cholesterol were differently related with typical and atypical CHD deaths, suggesting different etiologies for these coronary diseases.

Riskard 2005. New tools for prediction of cardiovascular disease risk derived from Italian population studies

BACKGROUND AND AIM

The need to update tools for the estimate of cardiovascular risk prompted the "Gruppo di Ricerca per la Stima del Rischio Cardiovascolare in Italia" to produce a new chart and new software called Riskard 2005.

METHODS AND RESULTS

Data from 9 population studies in 8 Italian regions, for a grand total of 17,153 subjects (12,045 men and 5,108 women) aged 35-74 and for a total exposure of about 194,000 person/years were available. A chart for the estimate of cardiovascular risk (major coronary, cerebrovascular and peripheral artery disease events) in 10 years was produced for men and women aged 45-74 free from cardiovascular diseases. Risk factors employed in the estimate were sex, age (6 classes), systolic blood pressure (4 classes), serum cholesterol (5 classes), diabetes, and cigarette smoking (4 classes). Estimates were produced for absolute risk and for relative risk, the latter against levels expected in the general population that produced the risk functions. Software was produced for the separate estimate of major coronary, cerebrovascular and cardiovascular events (the latter made by coronary, cerebrovascular and peripheral artery disease of atherosclerotic origin) for follow-up at 5, 10 or 15 years, in men a women aged 35-74 years at entry and free from cardiovascular diseases. Risk factors employed here were sex, age, body mass index, mean physiological blood pressure, HDL cholesterol, non-HDL cholesterol, cigarette smoking, diabetes and heart rate. The output is based on several indicators: absolute risk, relative risk (as defined above), ideal risk (for a very favourable risk profile), biological age of risk, comparisons among the above indicators, the percent contribution of risk factors to the excess of estimated risk above the level of the ideal risk, and the description of trends in risk estimate in relation to repeated measurements.

CONCLUSIONS

These tools represent progress compared to similar tools produced some years ago by the same Research Group.

Forty-year mortality from cardiovascular diseases and their risk factors in men of the Italian rural areas of the Seven Countries Study

OBJECTIVE

Forty-year cardiovascular mortality and its association with entry risk factor levels are reported for men enrolled in the Italian Rural Areas of the Seven Countries Study of Cardiovascular Diseases.

METHODS AND RESULTS

Cardiovascular risk factors were measured in 1712 men aged 40-59 years at entry examination in 1960. Mortality data were collected during 40 years of follow-up. Overall death rate was 83.7%. The main causes of death were cardiovascular diseases, with a preponderance of those of atherosclerotic origin (CVDA, 33.7 % of all causes) including coronary heart disease, stroke and peripheral arterial diseases. Using 14 risk factors measured at baseline, multivariate analysis for CVDA showed that seven of them were strongly and significantly associated with events. The multivariate hazard ratio for 5 years of age was 1.59 (CI 1.43-1.77); for heavy job-related physical activity it was 0.96 (CI 0.79-1.18); for 10 cigarettes smoked per day 1.16 (CI 1.05-1.28); for 20 mm Hg of systolic blood pressure 1.38 (CI 1.25-1.52); for 1 mmol/l of serum cholesterol 1.19 (CI 1.09-1.30); for 0.25 l/m2 of height of vital capacity 0.87 (CI 0.78-0.97); for the presence of corneal arcus 1.36 (CI 1.03-1.79). Risk factors of which the coefficient did not reach statistical significance were family history for cardiovascular diseases, forced expiratory volume, heart rate, mid-arm circumference, subscapular skinfold, body mass index and diabetes. Similar findings were obtained for CHD and partially for stroke mortality.

CONCLUSIONS

During a 40-year period classical cardiovascular risk factors were still highly predictive of cardiovascular diseases of atherosclerotic origin in these Italian rural populations.

Long-term trends in major cardiovascular risk factors in cohorts of aging men in the European cohorts of the Seven Countries Study

BACKGROUND AND AIMS

Time trends in major cardiovascular risk factors are described in cohorts of middle-aged men followed for 35 years in 9 European cohorts of Finland, The Netherlands, Italy, Serbia and Greece.

METHODS

Men aged 40 to 59 years at entry in the early 1960s were repeatedly re-examined 3 to 5 times over the last 35 years. Systolic blood pressure, serum cholesterol, body weight and body mass index were considered for analysis, including study of aging (35 years of follow-up) and of generation effects (10 years for men aged 50-59 in the period 1960-1970 and separately 10 years for men aged 75-84 years in the period 1985-1995).

RESULTS

For the aging effect, average systolic blood pressure increased approximately 15 mmHg over 25 years maintaining a steady state thereafter, the largest increases being found in Serbia and Greece. Average serum cholesterol varied between approximately 4.5 in Serbia and 6.5 mmo/L in Finland in about 1960. Twenty-five years later, the average level was about 6 mmol/L in all five countries and decreased slightly thereafter. Average body weight and body mass index increased in all countries for 25 years and levelled off thereafter. For the generation effect, average systolic blood pressure decreased in all countries, with the exception of men aged 50-59 in Serbia and men aged 75-84 in The Netherlands. Average serum cholesterol uniformly increased in men aged 50-59 for the younger age-class and slightly decreased in men aged 75-84. Average body weight and body mass index increased systematically in all countries and in both age groups.

CONCLUSIONS

Major changes were the great increases in average systolic blood pressure and serum cholesterol level in Serbia and in systolic blood pressure level in Greece between 1960 and 1985, and the large decrease in average serum cholesterol in Finland between 1970 and 1995. Average body weight and body mass index showed universal increases in both middle-aged and older men after 1960.

Early and late coronary deaths in the US Railroad study predicted by major coronary risk factors

BACKGROUND

The purpose of this study was to explore the duration of the association of major coronary risk factors measured on a single occasion with coronary heart disease (CHD) deaths during 40 years in a population sample of middle-aged men.

DESIGN

Measurement of age, systolic blood pressure, serum total cholesterol, and cigarette smoking was made on a single occasion in 2376 cardiovascular disease free men, aged 40-59, belonging to the US Railroad cohort of the Seven Countries Study enrolled in the late 1950s. During 40 years of follow up 627 men died from typical CHD (sudden death coronary death or definite myocardial infarction).

METHODS

Eight partitioned proportional hazards models were solved, one for each independent 5-year block of follow up, to predict the risk of CHD death. Eight 5-year partitioned hazard scores, derived from the coefficients, were cumulated for each risk factor.

RESULTS

The resulting curves showed a regularly increasing time trend in risk for coronary deaths as a function of serum cholesterol, systolic blood pressure and cigarette smoking, for the first 30-35 years of follow up followed by a loss of predictive power thereafter. The curves fit straight lines, with large squared correlation coefficients ranging from 0.96 to 0.99. There was a relatively constant strength in the association of risk factors levels with events, which are predicted irrespective of the distance from risk factor measurements.

CONCLUSIONS

Measurement of major coronary risk factors taken on a single occasion in middle-aged men maintained a regular and almost monotonic relationship with the subsequent occurrence of CHD deaths for at least 30-35 years of follow up.

Forty-year mortality from cardiovascular diseases and all causes of death in the US Railroad cohort of the Seven Countries Study

Forty-year mortality and its association with entry risk factor levels is reported in men employed in the US Railroad industry within the Seven Countries Study of Cardiovascular Diseases. Cardiovascular risk factors were measured in 2571 men aged 40-59 at entry examination in 1957-1959 and after 5 years. Mortality data were collected during 40 years of follow-up (overall mortality of 83.4%). The main causes of death were coronary heart disease (CHD, 32.9% of all causes using strict criteria), atherosclerotic cardiovascular diseases (including coronary, stroke and peripheral artery diseases, (ACVD), 53.2% of all causes) and cancer (25.1% of all causes). Multivariate analysis showed that age, systolic blood pressure, serum cholesterol and cigarette consumption were strongly and significantly associated with all-cause mortality, coronary mortality and cardiovascular mortality. Multivariate relative risks per 5 years of age were 1.31 for all-causes, 1.32 for CHD and 1.36 for ACVD; per 20 mmHg systolic blood pressure were 1.12, 1.23 and 1.26, respectively; per 1 mmol/l of serum cholesterol were 1.06, 1.18 and 1.14, respectively; and per 10 cigarettes smoked per day were 1.14, 1.12 and 1.13, respectively. During a 40-year period classical cardiovascular risk factors were highly predictive of coronary, cardiovascular and all-cause mortality in a US working population.

Mediterranean Adequacy Index: correlation with 25-year mortality from coronary heart disease in the Seven Countries Study

BACKGROUND AND AIM

The Mediterranean Adequacy Index (MAI) is an overall indicator characterising a diet in comparison with a Reference Mediterranean Diet. We computed the MAI of random samples of men surveyed for their eating habits in the 16 cohorts of the Seven Countries Study, and found that it inversely correlated with the 25-year death rates from coronary heart disease in the 16 cohorts (R = -0.72; p = 0.001). The correlation coefficient was -0.84 (p < 0.001) when the MAI was converted into natural logarithms.

CONCLUSIONS

These findings once again support the association between typical Mediterranean eating habits and protection against coronary heart disease.

The role of a baseline casual blood pressure measurement and of blood pressure changes in middle age in prediction of cardiovascular and all-cause mortality occurring late in life

OBJECTIVE

The first objective was to study the long-term association of a casual measurement of systolic blood pressure (SBP) with cardiovascular deaths (CVD) and all causes of death (ALL) occurring during 35 years of follow-up in different population samples of men aged 40-59 years in five European countries. The second objective was to study the predictive power of early change in SBP levels (years 0-10) in relation to late fatal events (years 10-35).

DESIGN, SETTING AND PARTICIPANTS

A single measurement of SBP was considered in cohorts in Finland, The Netherlands, Italy, Serbia and Greece for a total of 6507 men. Three partitioned proportional hazards models were solved, one for each independent and subsequent time block of 10 years, after excluding data from the first 5 years, to predict the risk of cardiovascular disease deaths of atherosclerotic origin (CVD) and all cause mortality (ALL). Independently, the predictive power of SBP changes (Delta-SBP) occurred during the first 10 years of follow-up was explored as a possible additional risk factor in relation to CVD and ALL deaths occurring between year 10 and year 35 of follow-up.

RESULTS

Partitioned hazard scores derived from the three partitioned functions were cumulated. The resulting curves showed a continuous and significant association of baseline SBP with CVD and ALL deaths during three decades, although the strength of association declined significantly from the first to the third decade. The relative risk for 20 mmHg of SBP (and its 95% confidence intervals) in predicting CVD deaths was 1.65 (1.54-1.77) for the first 10-year block; 1.33 (1.24-1.42) for the second block; and 1.22 (1.13-1.31) for the last 10-year block. The corresponding levels of ALL deaths were 1.41 (1.34-1.49), 1.26 (1.19-1.32) and 1.11 (1.05-1.17). Changes in SBP during 10 years (Delta-SBP) added predictive power to baseline measurements in a direct and significant way, with a relative risk for a change of 10 mmHg of 1.14 (1.10-1.17) for CVD deaths and 1.11 (1.09-1.13) for ALL deaths.

CONCLUSION

A single measurement of systolic blood pressure in middle-aged men maintains a strong relationship with fatal CVD and ALL deaths during the next 35 years, although for late events the strength of the association definitely declines. Changes in systolic blood pressure levels during the first 10 years of follow-up add predictive power, while baseline measurements retain their predictive power.

Time trends in three triennial surveys of cardiovascular risk factors and their treatment among patients discharged from divisions of internal medicine The FAPOI-1, FADOI-2, and FADOI-3 studies

BACKGROUND: There is increasing interest in monitoring cardiovascular risk factor levels and their treatment. We decided to study this in patients discharged from Divisions of Internal Medicine. METHODS: In three studies conducted in 1996, 1999, and 2002, data was collected on diagnoses of cardiovascular diseases and cardiovascular risk factor levels and treatment in 5904, 7476, and 9649 patients, respectively, aged 35 years or older, who were discharged within a week from 235, 345, and 517 Divisions of Internal Medicine in Italy. RESULTS: Between the first and third surveys, a relative decrease in atherosclerotic cardiovascular diseases was recorded, but heart failure showed a definite increase, reaching 11% of all cases. Mean levels of most cardiovascular risk factors decreased significant; only obesity did not. The proportion of treated hypertensives increased slightly (from 65% to 83% among men, and from 69% to 85% among women). The proportion of controlled hypertensives also rose, reaching around 37%. The proportion of treated dyslipidemics increased from 10% to 28% in men and from 12% to 25% in women, due to an increase in the use of statins. CONCLUSIONS: It is essential to focus attention on cardiovascular risk factors in order to optimize their treatment and to reduce cardiovascular disease.

Twenty-five-year coronary mortality trends in the seven countries study using the accelerated failure time model

The 'accelerated failure time model' (AFT) was tested in the 25-year experience of the Seven Countries Study, to describe the shape of hazard for coronary heart disease (CHD) mortality during long-term follow-up. Sixteen cohorts of men aged 40-59 at entry were enrolled in eight countries (USA, Finland, The Netherlands, Italy, Croatia, Serbia, Greece and Japan) for a total of 12,763 subjects. Risk factors were measured and CHD mortality data collected during 25 years. The AFT incorporating the Weibull survival distribution was applied to the pooled cohorts of each country, with CHD mortality as endpoint. Cumulative hazards and the annual hazard for CHD mortality were estimated during 25 years and compared among countries. The annual hazard for CHD in 25 years tended to reduce relatively or flatten out in the northern American and northern European countries, exponentially increased in Serbia and Japan, and increased moderately in the other countries of southern Europe. Positive correlations were found between the shape of the hazard curve and population mean risk factor changes (serum cholesterol and systolic blood pressure) observed during the first 10 years follow-up. The Japanese group was an outlier. The countries with the largest relative decline in the annual hazard function were the same where, during the same historical period, the largest decreases in official death rates from CHD were recorded and vice versa. The curve shape in the annual hazard for CHD mortality in different countries seems related to changes in mean levels of serum cholesterol and systolic blood pressure.

Trends in cardiovascular risk factors and their treatment among patients discharged from divisions of internal medicine. The FAPOI-1 and FADOI-2 studies

BACKGROUND

There is an increasing interest in monitoring cardiovascular risk factor levels and their treatment. Two studies were run in patients discharged from Divisions of Internal Medicine.

METHODS

Two studies, respectively conducted in 1996 and 1999, have collected data on the diagnoses of cardiovascular diseases and cardiovascular risk factor levels and treatment in 6450 and 8133 patients (age > or = 35 years) discharged during 1 week from 235 and 345 Italian Divisions of Internal Medicine.

RESULTS

The second survey revealed: a relative increase in heart failure and cerebrovascular disease diagnoses; lower serum levels of total cholesterol and triglycerides, lower systolic and diastolic blood pressure mean levels, and a decreased incidence of the habit of smoking among males. The proportion of treated hypertensives (blood pressure > or = 140/90 mmHg, or the use of antihypertensive drugs) increased slightly (65 to 68% among men and 69 to 71% among women). A reduction in the use of ACE-inhibitors was observed, balanced by an increase in the use of angiotensin II antagonists. The proportion of treated dyslipidemic patients (total cholesterol levels > or = 250 mg/dl, or HDL cholesterol levels < 35 mg/dl or triglyceride levels > or = 200 mg/dl or the use of hypolipidemic drugs) significantly increased from 10 to 25% among males and from 12 to 25% among females, due to a substantial increase in the use of statins.

CONCLUSIONS

During a 3-year period increasing attention for cardiovascular risk factors and their treatment among patients discharged from Divisions of Internal Medicine has been documented. In particular, there has been a large increase in the use of statins, although large segments of patients may need further attention and drug treatment.

Coronary risk factors predicting early and late coronary deaths

OBJECTIVE

To study the time related association of a single measurement of coronary risk factors with coronary heart disease (CHD) deaths occurring during a very long follow up period in a population sample of middle aged men.

DESIGN, SETTING, AND METHODS

Age, systolic blood pressure, serum total cholesterol, physical activity at work, body mass index, and cigarette smoking were measured once in 1622 CHD-free men aged 40-59 belonging to the Italian rural cohorts of the seven countries study. During 35 years of follow up 214 men died from CHD (sudden death and definite myocardial infarction). Seven partitioned proportional hazards models were solved, one for each independent five year block of follow up, to predict the risk of CHD death.

RESULTS

The seven, five year partitioned hazard functions were cumulated and smoothed for each risk factor. The resulting curves showed a regularly increasing time trend in risk for coronary deaths as a function of age, serum cholesterol, systolic blood pressure, and cigarette smoking and a regularly decreasing risk for physical activity. The curves fit straight lines, with large squared correlation coefficients ranging from 0.92-0.97. This suggests a relatively constant strength in the association of risk factor levels with events, which are predicted whatever the length of time after risk factors were measured. These findings were not altered by adding to the models risk factor changes preceding the quinquennium of death.

CONCLUSION

A single measurement of some coronary risk factors in middle aged men maintains a regular and almost monotonic relation with the occurrence of CHD deaths during 35 years of follow up.

Red blood cell count in short-term prediction of cardiovascular disease incidence in the Gubbio population study

OBJECTIVE

The Gubbio Study is an Italian population study measuring risk factors and incidence for major cardiovascular diseases. This analysis investigates the association between red blood cell (RBC) count, after preliminarily taking into account haematocrit, and incidence of coronary and cardiovascular events.

METHODS

A population sample of 2,469 men and women aged 35-74 years, free from major cardiovascular diseases and in whom RBC count and haematocrit were measured in 1983 along with other standard risk factors, were followed up for 6 years and incidence was estimated for both fatal and non-fatal coronary heart disease (CHD) and all cardiovascular atherosclerotic (CVD) events. Proportional hazards models were solved for the prediction of these events.

RESULTS

In six years 61 CHD hard criteria, 109 CHD any criterion and 149 CVD events were recorded. Preliminarily, both haematocrit and RBC count, two highly correlated variables, were studied to predict CVD events; however, haematocrit did not contribute multivariately, in the overall population and separately in men and women. Age-adjusted rates per 1,000 of the 3 event categories were computed in sex-specific RBC count quintiles (Q) and a difference was observed between Q5 and Q1 (with 5.21 +/- 0.31 and 4.18 +/- 0.23 x 10(6) per microl, respectively) for CHD any criterion (p < 0.07) and CVD (p < 0.05). P on trends was < 0.05 for both end-points. In multivariate models, adjusted for 7 other risk factors, RBC count contributed a weak statistical significance to predict CVD incidence [relative risk (RR) for a 0.5 x 10(6) per microl difference 1.23 with 95% confidence intervals (CI) 1.00- 1.51], whereas its contribution to predict CHD any criterion (RR = 1.19 with CI 0.93- 1.51) and CHD hard criteria (RR = 1.15 with Cl 0.83-1.58) was not statistically significant. Inclusion of blood glucose and presence of diuretics (11.33% of the population) as possible confounders had no major effect although the latter were, as expected, a significant risk factor (RR = 1.90 with Cl 1.28-2.82) which further diluted the CVD predictive role of RBC count (RR = 1.22 with CI 0.99- 1.50).

CONCLUSIONS

Increased RBC count is independently (yet weakly) associated with risk of CVD events in the 6-year follow-up of the Gubbio Study. Longer follow-up is needed before the contributory role of RBC count can be properly assessed to explain CHD incidence.

Cardiovascular risk factors as determinants of 25-year all-cause mortality in the seven countries study

This analysis aims at describing all-cause mortality and their determinants in 16 cohorts of middle-aged men of eight nations. A total of 12,763 men aged 40-59 years were enrolled in the late 1950s and early 1960s in 16 cohorts located in the USA, Finland, The Netherlands, Italy, Croatia, Serbia, Greece and Japan. The highest death rates were found in Slavonia-Croatia, due to high rates of infectious diseases and violence (death rate of 610 per 1000), and in East Finland due to high rates from coronary heart disease (death rate of 597 per 1000). The lowest death rates were found in a highly educated group in Belgrade, Serbia (death rate 295 per 1000) and in Crete, Greece (death rate 314 per 1000). The ecological analysis showed no significant relationship between mean risk factor levels and all-cause death rates except for the direct association with systolic blood pressure during the first 15 years follow-up. Individual multivariate analysis on eight national pools showed that age, systolic blood pressure, and smoking habits are direct, significant, and universal long-term predictors of all-cause mortality. Serum cholesterol, physical activity and body mass index were so only in some areas. Multivariate coefficients were similar across nations. Pooled hazards ratios were 1.55 for a difference of 5 years of age (CI: 1.51-1.59); 1.23 for 10 cigarettes smoked per day (CI: 1.20-1.26); 0.91 for one unit (based on three grades) of physical activity score (CI: 0.87-0.95); 1.04 for 1 mmol/l of serum cholesterol (CI: 1.02-1.07); and 0.93 for three units of body mass index (CI: 0.91-0.96). In conclusion some cardiovascular risk factors predict long-term risk of all-cause mortality in different cultures.

The estimate of cardiovascular risk. Theory, tools and problems

The present article reviews the epidemiological and statistical bases of the multivariate prediction of cardiovascular events and its transformation into practical tools for primary prediction. The problems with the use of tools derived from studies conducted in populations that are different from those in which the estimate is being made are documented. A description is made of a number of predictive tools produced in the past and recently included in risk manuals, charts and computer programs and their main characteristics are outlined. The problems in the origin, structure and use of the chart suggested by the Task Force of three European Scientific Societies, including the marked overestimate of the risk when this tool is applied to Italian data, are reviewed in detail. The need to use predictive tools derived from Italian population studies is stressed. Comments are made on the difficult choice between the use of the absolute and relative risks for the identification of high-risk subjects to be treated on an individual basis for primary prevention of major cardiovascular diseases.

Prediction of early and delayed postoperative deaths after coronary artery bypass surgery alone in Italy. Multivariate predictions based on Cox and logistic models and a chart based on the accelerated failure time model

BACKGROUND

The aim of the multicenter OP-RISK (OPerative RISK) study was to investigate the early (28 days) and delayed (365 days) death rates following coronary artery bypass grafting (CABG) among patients representing a nationwide distribution [Centers in Northern (2), Central (1) and Southern (1) Italy] and further to define the multivariate risk factors for the early and delayed mortality after CABG.

METHODS

Data were collected from 1126 patients undergoing CABG alone. Data were analyzed using Cox and logistic regression models, to accurately assess the major factors influencing survival over time after CABG. Having defined the significant factors, we constructed a chart of the absolute early risk of mortality using the accelerated failure time model.

RESULTS

Using the Cox proportional hazards model and logistic regression we have demonstrated that age, preoperative ejection fraction and heart rate, and the duration of aortic cross-clamping are multivariate risk factors in the short and long term. The role of one arterial conduit was also assessed.

CONCLUSIONS

The OP-RISK study produced relevant information for risk assessment and control in CABG and the results may form the basis for the objective quality assurance and accreditation of cardiac surgical institutions in Italy. Incidentally, Cox model appeared more adequate than logistic model for the assessment of the major factors influencing survival over time after CABG. The risk factors so assessed were used to construct a chart for practical predictive purposes.

The risk functions incorporated in Riscard 2002: a software for the prediction of cardiovascular risk in the general population based on Italian data

BACKGROUND

The purpose of this analysis was to produce risk functions for the prediction of cardiovascular diseases based on Italian epidemiological data and suitable for the use in a PC program dedicated to the estimate of risk.

METHODS

Three studies were used for the purpose: the Italian Rural Areas of the Seven Countries Study, the Gubbio Population Study and the ECCIS study, for a total of 9771 men and women aged 35 to 74 years and followed for a period lasting 5 to 6 years. The risk factors used for the prediction of cardiovascular events were sex, age, body mass index (derived from height and weight), mean blood pressure (derived from systolic and diastolic blood pressures), non-HDL cholesterol (derived from total and HDL cholesterol), HDL cholesterol, diabetes (yes-no), heart rate, and daily cigarette consumption. The endpoints were the first major coronary event, the first major cerebrovascular event, and the first major cardiovascular event (either one between the previous two plus major peripheral artery diseases). The model employed for the analysis was the accelerated failure time model.

RESULTS

Having excluded those already presenting with a cardiovascular disease and those with missing values, a total of 9089 subjects were included in the models. In a period lasting 5 or 6 years, a total of 211 coronary, 64 cerebrovascular and 269 cardiovascular events occurred and were considered for analysis. Coefficients from the coronary model suggested a significant association of all risk factors except body mass index and diabetes (marginal significance). Coefficients from the cerebrovascular model suggested a significant association limited to age and mean blood pressure. Coefficients from the cardiovascular model suggested a significant association of all risk factors except body mass index. The discrimination between cases and non-cases was satisfactory with proportions of 37.0, 52.3 and 37.8% of observed cases in decile 10 of the distribution of the estimated risk for the three endpoints respectively.

CONCLUSIONS

The three models were used as a mathematical core for the construction of a PC software for the prediction of major cardiovascular events in Italy.

An Italian chart for cardiovascular risk prediction. Its scientific basis

A risk chart for primary prediction of major coronary and cerebrovascular events based on Italian population data was created. Material from three Italian population studies was available: the Italian Rural Areas of the Seven Countries Study (no. 1712), the Gubbio Study (no. 3061) and the ECCIS Study (no. 4998) for a total of 9771 men and women aged 35 to 74 years and followed-up from 5 to 15 years, for a total of over 55,000 person/years. Sex, age, diabetes, cigarette smoking, systolic blood pressure and serum cholesterol were selected as risk factors, while the endpoint was established as the occurrence of the first major coronary or cerebrovascular event in 10 years. The accelerated failure time model was used as the predictive model. Two models were adopted, i.e., for relatively younger subjects (45-59 years) and for relatively older subjects (60-74 years). Both produced highly significant coefficients for each of the selected risk factors. The two models carried a satisfactory discriminating power, with 40% to more than 50% of all events located in the upper quintile of the estimated risk. Sex, age (6 classes), diabetes, cigarette smoking (4 classes), systolic blood pressure (4 classes) and serum cholesterol (5 classes) were considered for the creation of a risk map derived from multivariate models. A total of 1920 cells were filled with different colors corresponding to 6 classes of absolute risk. A similar set of cells was filled with another color scale for the estimate of the relative risk versus subjects of the same age and sex carrying Italian mean levels of risk factors. The chart is being distributed to the Italian medical profession as a practical tool to select high-risk individuals for the primary prevention of major cardiovascular diseases.

Serum uric acid for short-term prediction of cardiovascular disease incidence in the Gubbio population Study

OBJECTIVE

The Gubbio Study is an Italian population study measuring risk factors for and incidence of major cardiovascular diseases. This analysis investigates the association of serum uric acid with the incidence of coronary and cardiovascular events.

METHODS

A population sample of 2469 men and women aged 35-74 years, free from major cardiovascular diseases and in whom serum uric acid was measured in 1983 along with other standard risk factors, were followed up for 6 years and the incidence of coronary heart disease (CHD) and all cardiovascular atherosclerotic (CVD) events, both fatal and non-fatal, was computed. Proportional hazards models were used for the prediction of these events.

RESULTS

In six years 61 CHD hard criteria, 109 CHD any criterion and 149 CVD events were recorded. Age-adjusted rates per 1000 of the 3 event categories were computed in sex-specific quintiles (Q) of serum uric acid with 428 +/- 76 (Q5) and 198 +/- 42 (Q1) micromol/l, respectively. Although higher rates were seen in Q5 as compared to Q1 for all three first event categories considered (relative risks 6.2, 3.6 and 3.7, respectively), a statistically significant trend was seen only for CVD all criteria (t = 3.63, p < 0.036). These trends were borderline significant for CHD any criterion (t = 2.92, p < 0.06) and not significant for CHD hard criteria (t = 2.23, p < 0.11). In multivariate models, adjusted for 8 other risk factors, serum uric acid showed a statistically significant contribution to predict CVD incidence [relative risk (RR) for 92 micromol/l difference of 1.24 with 95% confidence intervals (CI) 1.05-1.45], whereas the statistical contribution to predict CHD any criterion (RR = 1.19 with CI 0.98-1.45) and CHD hard criteria (RR = 1.20 with CI 0.93-1.55) was not significant. Diuretic treatment and blood urea, as further confounders, were positively and significantly related to event incidence (RR ranging from 1.21 to 2.00) but serum uric acid maintained its independent and statistically significant role in the prediction of CVD events (RR = 1.18 with CI 1.00-1.39). Presence of specific treatments to lower serum uric acid levels (in 1.13% of the population), tested as final confounders, was not statistically contributory.

CONCLUSIONS

Increased serum uric acid levels are independently and significantly associated with risk of CVD events in the 6-year follow-up of the Gubbio Study. Longer follow-up is needed before the contributory role of serum uric acid can be properly assessed to explain CHD incidence.

Impact of the Gubbio population study on community control of blood pressure and hypertension. Gubbio Study Research Group

BACKGROUND

Awareness and treatment of hypertension have markedly increased in the last 30 years in most parts of the world, but a satisfactory control of blood pressure is still infrequent

OBJECTIVES

To describe trends in community control of hypertension and blood pressure levels in the small town of Gubbio, Italy.

METHODS

Large samples of the populations (aged 30-79 years) were examined 6 years apart for measurement of blood pressure, other cardiovascular risk factors and knowledge, attitude and practice towards control of hypertension. Data were available from a total of 1125 men and 1445 women with two examinations and 1566 men and 1658 women with at least one examination. Two different definitions of hypertension were used (old definition: systolic blood pressure (SBP) > or = 160 mmHg or diastolic blood pressure (DBP) > or = 95 mmHg or use of antihypertensive drugs; recent definition: SBP > or = 140 mmHg or DBP > or =90 mmHg or use of anti-hypertensive drugs).

RESULTS

Awareness, treatment and control of hypertension increased from one survey to the other, whatever definition of hypertension was used. Control rose from 41 to 63% (old definition) and from 12 to 24% (recent definition). In a 6-year period, the average population SBP declined 2-8 mmHg and DBP declined 2-3 mmHg depending on type of analysis, against an expected rise of 9 mmHg for SBP and 2 mmHg for DBP. These trends are partly explained by a marked decline in alcohol consumption and by more common and intensive anti-hypertensive treatment, while change in body mass index, which showed a slight but systematic increase, cannot be considered as a contributor to this trend.

CONCLUSIONS

An epidemiological study has motivated a population group and its medical profession towards a better control of hypertension.

[Notes to the regulatory Appendix 13 of the Italian Committee for Drugs]

The Italian Committee for Drugs has recently modified "Appendix 13" to a recent Italian regulation related to reimbursement of hypolipidemic agents for primary or secondary prevention of heart diseases. There is some confusion in concepts, terminology and phrasing, also dealing with disease definition, which need comment. Moreover, "Appendix 13" suggests to estimate risk based on charts derived from the Framingham experience, which are inappropriate when applied to Italy. Finally, "Appendix 13" is not clear as to how categorize high risk individuals. There has been a growing interest in estimating coronary risk since 1994, probably as the result of primary and, secondary intervention trials with statins used to lower blood cholesterol levels. On the other hand, European guidelines have been published, accompanied by risk charts (derived from the Framingham study) helping to index individuals who may benefit from treatment of coronary risk factors. At least thirteen such or similar instruments have been produced worldwide (and three of these in Italy) to estimate coronary risk. In Italy, there are other instruments in preparation. Data are reviewed wherefrom it is possible to conclude that it is inadequate, since substantially erroneous, to use risk functions to estimate absolute coronary risk when these are derived from largely different populations as to those in which practical applications are looked for.

The duration of the association between serum cholesterol and coronary mortality: a 35-year experience

OBJECTIVE

Our purpose was to study the time-related association between a single measurement of total serum cholesterol and the occurrence of coronary deaths in a population sample of middle-aged men.

DESIGN

This is a longitudinal population study with multiple measurements of serum cholesterol and a 35-year follow-up for coronary mortality in 1622 coronary disease-free men aged 40-59 years belonging to the Italian rural cohorts of the Seven Countries Study.

METHOD

A single measurement of serum cholesterol (plus those of five other risk factors as possible confounders) was considered. During 35 years of follow-up, 214 men died from coronary heart disease. Annual partitioned proportional hazards models were solved, one for each independent year of follow-up, to predict the risk of coronary heart disease deaths. Single-year hazard functions were cumulated and smoothed. Similar analyses were made starting from cholesterol measurements taken at years 5, 10 and 20 of follow-up.

RESULTS

The resulting hazard curves showed regularly increasing risk for coronary events and fitted straight lines with large correlation coefficients, demonstrating a strong association of serum cholesterol with both early and late events. The slopes were steeper for cholesterol measurements taken at younger ages. The slope for cholesterol measurement taken at year 20 (age 60-84 years) was flat. In slopes starting at an early age, two components could be isolated corresponding to different associations with events (stronger for early events when measurements were taken around the age of 50 years and for late events when measurements were taken around the age of 55 or 60 years).

CONCLUSION

A single measurement of total serum cholesterol in middle-aged men maintains a relatively monotone relationship with the occurrence of coronary heart disease deaths over 35 years. In the study population, measurements taken in late adulthood had smaller or null association with coronary disease deaths.

Twenty-five-year cardiovascular disease incidence among middle-aged men. Disease burden, time shape, predictors, risk probabilities

BACKGROUND

This analysis aims at describing the 25-year experience in cardiovascular incidence in a sample of middle-aged men in rural Italy.

METHODS

A total of 1712 men aged 40-59 years were examined in 1960 in two rural Italian cohorts belonging to the Seven Countries Study. Major risk factors were measured and a monitoring system for incidence of cardiovascular events was in operation for the next 25 years centered on the first event occurring within each subgroup of cardiovascular diseases. Data were modeled by the Weibull distribution incorporated in the accelerated failure time model.

RESULTS

Among 1695 cardiovascular disease-free men at entry, 51.3% experienced at least one cardiovascular event, the first being a coronary heart disease (35.6%), a cerebrovascular disease (17.8%) or a peripheral artery disease (13.0%). Among all first events the most common was intermittent claudication (17.6%), followed by angina pectoris (16.6%). A proportion of 13% of all initial episodes was rapidly fatal, whereas 38 % of subjects developing a cardiovascular event died within the 25-year deadline. Age, cigarette smoking, diabetes, corneal arcus, serum cholesterol, systolic blood pressure, and vital capacity fed into the accelerated failure time model showed a statistically significant association with cardiovascular disease incidence (inverse for vital capacity). The same model provided the shape of hazard during the 25 years with major events continuing to appear in an increasing exponential fashion, while soft criteria events were less likely to appear as a first event in the late phase of follow-up.

CONCLUSIONS

In middle-aged men 25-year incidence of cardiovascular diseases is high and more relevant compared to that of traditional hard criteria coronary heart disease that in the past has attracted almost exclusive interest.

Coronary heart disease incidence in northern and southern European populations: a reanalysis of the seven countries study for a European coronary risk chart

OBJECTIVE

A systematic reanalysis of 10 year coronary heart disease incidence data from the northern and the southern European cohorts of the seven countries study, to contribute indirectly to the production of a European coronary risk chart.

DESIGN AND SETTING

Men aged 40-59 years at entry were studied in three northern European cohorts based in Finland and Netherlands (n = 2213); and in 10 southern European cohorts based in Italy, former Yugoslavia, and Greece (n = 5897). Multiple logistic models for the prediction of coronary deaths, coronary incidence (hard criteria), and coronary incidence (any criterion) were solved for the two geographical groups and their pool. Risk factors fed into the models were age, systolic blood pressure, serum total cholesterol, and cigarette smoking.

RESULTS

10 year coronary heart disease mortality and incidence were higher in northern than in southern Europe, with ratios around 2.65. Ratios among the three coronary heart disease manifestations were identical in the two cultural groupings. Coefficients of the multiple logistic models were similar and not significantly different between the two groupings. When applying the coefficients back to the same or the opposite population, the relative risk was large and similar in the different cultures. Relative risk was larger for more severe coronary heart disease manifestations. The absolute risk was overestimated when applying the northern European model to southern European populations and vice versa, with ratios of about 1.5 and 0.5, respectively. Coronary risk charts created to reproduce the shape of those incorporated in recent European guidelines confirmed the excess of absolute risk in the northern compared with the southern European cohorts, all else being equal.

CONCLUSIONS

In theory, a more appropriate European coronary risk chart could be produced by adopting coefficients to correct for different background incidence rates in different cultures. Other coefficients could appropriately be used to transform mortality risk into incidence risk.

First risk functions for prediction of coronary and cardiovascular disease incidence in the Gubbio Population Study

BACKGROUND

The Gubbio study is an Italian population study which measures the risk factors and incidence of major cardiovascular diseases. This analysis produces multivariate models for the prediction of cardiovascular end-points.

METHODS

A population sample of 2,963 men and women aged 35-74, free from major cardiovascular diseases, was examined in 1983 with risk factor measurement, and a 6-year incidence was computed for coronary heart disease and all cardiovascular (atherosclerotic) events. Proportional hazards models were solved for the prediction of these events.

RESULTS

Over a 6-year period, 74 hard criteria, and 126 any criterion coronary heart disease and 174 cardiovascular events were recorded. Multivariate models showed the predictive power of sex (relative risk ranging 1.63 to 2.60), age (relative risk for 5-year difference ranging 1.38 to 1.48), systolic blood pressure (relative risk for 20 mmHg difference ranging 1.17 to 1.27), HDL cholesterol (relative risk for a difference of 10 mg/dl ranging 0.73 to 0.81), non-HDL cholesterol (relative risk for 40 mg/dl difference ranging 1.15 to 1.27), cigarette smoking (relative risk for 10 cigarette difference ranging 1.21 to 1.28), and body mass index (relative risk for 3 units ranging 0.99 to 1.02). All coefficients were statistically significant except that for body mass index, they were larger for hard criteria coronary heart disease, and their magnitude was similar to that found in previous Italian population studies.

CONCLUSIONS

Traditional cardiovascular risk factors predict coronary and cardiovascular events in another Italian population study confirming previous findings and similar predictive models.

Long-term time-related predictivity of coronary events as a function of a single measurement of serum cholesterol and systolic blood pressure

OBJECTIVE

To study the time-related association of a single measurement of serum cholesterol and systolic blood pressure with the occurrence of a first coronary event in a population sample of middle-aged men.

METHODS AND RESULTS

A single measurement of serum total cholesterol and systolic blood pressure (along with age, cigarette consumption, physical activity at work and body mass index as possible confounders) was made in 1,605 coronary disease-free men aged 40-59 belonging to the Italian rural cohorts of the Seven Countries Study. During 25 years of follow-up 353 men developed a first event, that is a coronary death (sudden or not), and definite or possible myocardial infarction. Twenty-five partitioned proportional hazards models were solved, one for each independent year of follow-up, to predict the risk of incident events. Single-year hazard functions, separately for serum cholesterol and systolic blood pressure, were cumulated and smoothed. The resulting curves showed a regularly increasing risk for coronary events. They fit straight lines, with large correlation coefficients for both serum total cholesterol (r = 0.99) and systolic blood pressure (r = 0.99). These slopes were similar to the coefficients estimated by a single proportional hazards model solved for all events during 25 years.

CONCLUSION

A single measurement of serum total cholesterol and systolic blood pressure in middle aged-men maintains a regular and monotonic relationship with occurrence of a first coronary event during 25 years of follow-up.

Comparison of the Framingham risk function-based coronary chart with risk function from an Italian population study

AIMS

The aim is to compare the coronary risk chart published by the European Task Force for Prevention of Coronary Heart Disease and produced using a Framingham risk function, with a risk function derived from an Italian population study.

METHODS AND RESULTS

Coronary risk function in this study was the result of longitudinal experience in an Italian middle-aged population of 1656 male subjects followed-up for 25 years. To comply with the Framingham equation the same risk factors (age, systolic blood pressure, total serum cholesterol and smoking habits), end-points (any possible coronary event including angina pectoris), and length of follow-up (10 years) were used, and the model (log-linear accelerated time failure model, accommodating the Weibull distribution) was similar. Comparisons were made computing the coronary risk for each cell of the coronary risk chart for men aged 40, 50 and 60 years. The Italian risk function produced highly significant coefficients for all four risk factors. Forty-four out of a total of 120 cells had a coronary risk of 20% or more in 10 years following the coronary risk chart, whereas this was reduced to four while using the Italian risk function (P<0.001). The Italian risk function largely underestimated the corresponding levels produced by the coronary risk chart and vice versa.

CONCLUSION

The Framingham risk function-based coronary risk chart overestimates absolute coronary risk in countries characterized by a lower incidence of coronary events and should be used with caution.

[The prevalence and clinical characteristics of heart failure in a population sample of Calabria]

Two-hundred and fourteen patients with congestive heart failure were identified over a six-month period in the general practice of 29 GPs covering an adult population of 29,959 subjects residing in the region of Calabria, in southern Italy, with an overall prevalence of 7 per 1000. Males represented 52% of the cases and females 48%, with a median age of 75 years. On average, the condition was first diagnosed 41 months before the present examination. Patients generally had a high body mass index (28 kg/m2). Patients were classified as follows in the NYHA classification: 9.4% in class I, 45.3% in class II, 39.2% in class III, 6.1% in class IV. Hypertension, either alone or associated with ischemic heart disease (totally about 75% of cases), was the most common etiology, while COPD was the most commonly associated chronic condition. Clinical symptoms and signs were used to classify patients in a simplified version of the Boston score which was reported in 48% of cases as definite, 12% as possible, 6% as improbable and 34% as absent. A specific treatment was already ongoing in 97% of patients. The most commonly administered drugs were diuretics (83%), ACE-inhibitors (77%), and digitalis (67%). This three-drug combination (alone or with other drugs) covered 46% of patients. A comparison of four predefined typologies of treatment against the Boston score suggested that at least part of the outcome in classifying patients using this procedure was due to pathomorphosis of the syndrome induced by early pharmacological treatment.

Role of body mass index in the prediction of all cause mortality in over 62,000 men and women. The Italian RIFLE Pooling Project. Risk Factor and Life Expectancy

STUDY OBJECTIVE

To evaluate the relation of body mass index (BMI) to short-term mortality in a large Italian population sample.

DESIGN

Within the Italian RIFLE pooling project, BMI was measured in 47 population samples made of 32,741 men and 30,305 women ages 20-69 years (young 20-44, mature 45-69). Data on mortality were collected for the next six years.

MAIN OUTCOME MEASURES

Age adjusted death rates in quintile classes of BMI and Cox proportional hazards models with six year all causes mortality as end point, BMI as covariate and age, smoking, systolic blood pressure as possible confounders were computed. Multivariate analysis was tested in all subjects and after the exclusion of smokers, early (first two years) deaths, and both categories.

RESULTS

The univariate analysis failed to demonstrate in all cases a U or inverse J shaped relation. The Cox coefficients for the linear and quadratic terms of BMI proved significant for both young and mature women. The minimum of the curve was located at 27.0 (24.0, 30.0, 95% confidence limits, CL) and 31.8 (25.5, 38.2, 95% CL) units of BMI, for young and mature women respectively. Similar findings were obtained even when exclusion were performed. No relation was found for young men while for mature adult men only the model for all subjects retained significant curvilinear relation (minimum 29.3; 22.4, 36.2, 95% CL).

CONCLUSION

These uncommon high values of BMI carrying the minimum risk of death seems to be in contrast with weight guidelines. A confirmation of these findings in other population groups might induce the consideration of changes in the suggested healthy values of BMI.

Twenty-five year mortality from coronary heart disease and its prediction in two Croatian cohorts of middle-aged men

Two cohorts of men aged 40-59 in geographically defined areas of Croatia, former Yugoslavia, were enrolled in 1958 and cardiovascular risk factors were measured. The cohort of Dalmatia, on the Adriatic coast, was made up of 671 men (participation rate 98%), that of Slavonia, in the inland plain, of 696 men (participation rate 91%). Similar examinations were repeated 5 and 10 years after the entry one. A complete follow-up for vital status and causes of death was run for 25 years. Death rates in 25 years from coronary heart disease (CHD) were 90 per 1000 in Dalmatia and 148 per 1000 in Slavonia where also all other major causes of death and all-cause mortality rates were higher (642 vs 465 per 1000 in 25 years). Univariate and multivariate analysis relating ten risk factors to CHD mortality, showed that age and systolic blood pressure were significant predictors in Dalmatia; age, subscapular skinfold and body mass index (inverse) in Slavonia; and age, systolic blood pressure and subscapular skinfold in a multivariate model with lumped cohorts, where dummy variables identifying cohorts indicated a large unexplained extra-risk in Slavonia. In the pooled analysis cigarette smoking and serum cholesterol carried non significant coefficients. Blood pressure change in the first 10 years of follow-up added predictivity to a model exploring the delayed CHD morality occurring between year 10 and 25 of follow-up. Among the base-line measurements only serum cholesterol was significantly different between the two groups (188 mg/dl in Dalmatia and 199 mg/dl in Slavonia).(ABSTRACT TRUNCATED AT 250 WORDS)

Indexes of obesity and all-causes mortality in Italian epidemiological data

BACKGROUND

The relationships of body mass index and skinfold thickness to all-causes mortality during a 10-year follow-up were assessed in 8,341 men and 1,100 women ages 30-69 years from different Italian population samples.

RESULTS

Among men, both univariate and multivariate analyses showed a clear-cut parabolic (inverse J-shaped) relationship, whose left branch became less steep after the exclusion of smokers, people carrying severe diseases at entry, those who died during the first 5 years, or all of them. The minimum risk was almost always located around 28 units of body mass index, and it decreased to smaller levels of body mass index when the exclusions were adopted. The analysis of skinfold thickness showed similar but less clear-cut results. Among women, due to the limited number of fatal events, the analysis was unable to show any clear relationship of body mass index or skinfold thickness to all-causes mortality. The multivariate analysis showed a similar parabolic relationship of body mass index to all-causes mortality. The estimated multivariate risk of death broken down into five quintiles was unrelated to the mean level of body mass index for each quintile. From the multivariate model it was estimated that an excess of 10 kg in body weight (above the body mass index corresponding to the minimum risk level and everything else being equal) carries the same excess of risk produced by 5 mm Hg of systolic blood pressure or by less than 5 cigarettes smoked per day.

CONCLUSION

These results suggest that high levels of obesity indicators are only slightly associated with an excess mortality and that overweight and obesity are health hazards only if they are accompanied by an elevation of other risk factors, mainly of blood pressure.

Time changes in predictability of coronary heart disease in an Italian aging population

A pool of two Italian rural population samples made up of 1,712 men aged 40-59 at entry was studied in 1960 and than followed up for 25 years. The multivariate analysis of the first major coronary event using the Cox model showed, in men aged 40-59, 45-64 and 50-69, the significant predictive role of age, systolic blood pressure, serum cholesterol and cigarette smoking, but not of body mass index, without marked differences attributable to the aging process. Changes in systolic blood pressure, serum cholesterol and cigarette smoking occurring between year 0, 5 and 10 of follow-up, as defined by two different indicators, increased significantly the predictability of coronary events occurring between years 10 and 25 of follow-up when added to the model including the baseline factors. It is inferred that increases and decreases (even of relative nature) of the three major risk factors around the entry levels are associated with higher and lower levels of coronary risk in the 15 years after the changes have occurred.

Multivariate prediction of the first major cerebrovascular event in an Italian population sample of middle-aged men followed up for 25 years

BACKGROUND AND PURPOSE

The present investigation was aimed at evaluating the incidence and prediction of a first major cerebrovascular (fatal or nonfatal) event.

METHODS

The study population included the two Italian rural samples of the Seven Countries Study (namely, Montegiorgio and Crevalcore), accounting for a total of 1,712 men aged 40-59 years at entry and followed up for mortality and morbidity for 25 years. A number of individual variables measured at baseline, at the fifth year, and at the tenth year of follow-up and possibly related to cerebrovascular events were considered. Of the 1,709 subjects free from major cerebrovascular events at entry 171 developed a first major cerebrovascular event, but for the multivariate Cox model analysis only 1,572 subjects and 152 events were employed due to some exclusions for missing data.

RESULTS

Systolic blood pressure, indexes of respiratory function (protective), and physical activity at work (protective) demonstrated significant predictive roles for all ages and all lengths of follow-up considered. Other factors (presence of arrhythmias, presence of arcus senilis, and skinfold thickness [protective]), significantly contributed to the prediction, but in only some models. Time-related changes in systolic blood pressure significantly improved the prediction of cerebrovascular events.

CONCLUSIONS

The multivariate prediction performed in this report allowed the validation of three risk factors (systolic blood pressure, respiratory function indexes, and physical activity at work) whose predictive powers remain stable with aging. The need for further studies specifically aimed at discriminating hemorrhagic from thrombotic events is suggested.