Explaining Poorer Stroke Outcomes in Women: Women Surviving 3 Months Have More Severe Strokes Than Men Despite a Lower 3-Month Case Fatality

BackgroundWomen who survive stroke are more disabled and more often institutionalized than men.ObjectiveWe explore this phenomenon by studying case fatality and stroke severity in stroke survivors separately for men and women.MethodsA Danish stroke registry (2000−2007) contains information about 26,818 patients with first-ever ischemic stroke, including stroke severity (Scandinavian Stroke Scale, 0 worst to 58 best), computed tomography scan, cardiovascular risk factors, and death 3 months after stroke. We modeled stroke severity by generalized additive linear model and 3-month case fatality with logistic model adjusting for age and cardiovascular risk factors.ResultsMale to female ratio was 51.5% to 48.5%. Mean age was 68.8 (SD 12.6) years in men; 73.7 (13.8) years in women. Stroke was more severe in women (mean [SD] Scandinavian Stroke Scale, 42.2 [16.0]) than in men (mean [SD] Scandinavian Stroke Scale, 45.6 [14.2]) also after adjustment for age and cardiovascular risk factors; significant in patients older than 75 years. In survivors at 3 months, stroke was more severe in women than men, given same age and cardiovascular risk factor profile; significant in patients older than 75 years. More women (11.9%) had died within 3 months than men (8.6%). However, adjusting for age, stroke severity, and risk factor profile, 3-month case fatality was lower in women than men; significant in patients older than 78 years.ConclusionsAlthough 3-month case fatality was lower in women than men, strokes were more severe among survivors at 3 months in women than in men. In addition, strokes were more severe in women. Our data help elucidate why women survive stroke better but have poorer functional outcomes that require more care than men.     

Are BMI and other anthropometric measures appropriate as indices for obesity? A study in an Asian population

We have examined the relationships between percentage of body fat (PBF) and risk factors for cardiovascular disease and insulin resistance and how good body mass index (BMI) and other anthropometric measures are as indices of obesity. High PBF levels were associated with increased risk of cardiovascular disease and insulin resistance. The World Health Organization BMI of 30 kg/m(2) for obesity has low sensitivity, 6.7% and 13.4% for men and women, respectively. For every obese man and woman identified, 6.7 and 1.76 times nonobese men and women, respectively, will be misclassified as obese. With the locally established BMI cutoff point for obesity of 27 kg/m(2) for men and 25 kg/m(2) for women, the sensitivity was improved to 46.7% and 60.8%, respectively. For every obese man and woman identified, 3.76 and 1.64 times nonobese men and women, respectively, will be misclassified as obese. None of the other anthropometric indices was better than the locally established BMIs. We showed that the BMIs for obesity for our local men and women are different. These BMIs were most precise among all indices studied. However, they still lead to high false-positive rates. For more effective management of the problem of obesity, we need to develop more precise, simple, and cost-effective methods for the measurement of PBF.     

Epidemiological modelling of routine use of low dose aspirin for the primary prevention of coronary heart disease and stroke in those aged ≥70

Objective To investigate the routine use of low dose aspirin in people aged ≥ 70 without overt cardiovascular disease.Design Epidemiological modelling in a hypothetical population.Setting Reference populations of men and women in the year 2000 from the state of Victoria, Australia.Subjects 10 000 men and 10 000 women aged 70-74 with no cardiovascular disease.Main outcome measures First ever myocardial infarction or unstable angina, ischaemic or haemorrhagic stroke, and major gastrointestinal haemorrhage. Health adjusted years of life lived.Results The proportional benefit gained from the use of low dose aspirin by the prevention of myocardial infarctions (-389 in men, -321 in women) and ischaemic stroke (-19 in men and -35 in women) is offset by excess gastrointestinal (499 in men, 572 in women) and intracranial (76 in men, 54 in women) bleeding. The results in health adjusted years of life lived (which take into account length and quality of life) are equivocal for aspirin causing net harm or net benefit.Conclusion Epidemiological modelling suggests that any benefits of low dose aspirin on risk of cardiovascular disease in people aged ≥ 70 are offset by adverse events. These findings are tempered by wide confidence intervals, indicating that the overall outcome could be beneficial or adverse.     

Comparisons of Different Metabolic Syndrome Definitions and Associations with Coronary Heart Disease,Stroke, and Peripheral Arterial Disease in a Rural Chinese Population

ObjectivesWe estimated the prevalence of metabolic syndrome (MetS) and compared associations of different MetS definitions with coronary heart disease (CHD), stroke, and peripheral arterial disease (PAD) in a rural Chinese population.MethodsAmong 4,748 residents (2,145 men and 2,603 women) aged 30+ years in rural China from 2006 to 2007, the prevalence of MetS was estimated by using five different definitions: modified World Health Organization (WHO), Chinese Diabetes Society (CDS), the updated National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) for Asian-Americans, International Diabetes Federation (IDF), and Joint Interim Statement (JIS). Multivariable logistic regression analyses were implemented to estimate the association between MetS and the prevalence of CHD, stroke and PAD, respectively.ResultsPrevalence of MetS in men was 11.5% (WHO), 14.8% (CDS), 32.4% (NCEP-ATP III), 27.5% (IDF) and 39.7% (JIS) and in women was 15.7% (WHO), 20.7% (CDS), 54.2% (NCEP-ATP III), 51.5% (IDF) and 54.2% (JIS), respectively. Respective ORs (95% CI) for associating MetS with CHD in men were 1.79 (1.02-3.17), 1.25 (0.69-2.26), 1.61 (1.01-2.58), 1.84 (1.14-2.96), and 1.53 (0.96-2.43). Corresponding ORs (95% CI) for stroke in men were 2.18 (95% CI 1.20 to 3.97), 2.20 (95% CI 1.25 to 3.89), 1.71 (95% CI 1.02 to 2.84), 1.30 (95% CI 0.77 to 2.23), and 1.61 (95% CI 0.97 to 2.68), respectively. In women, CHD and stroke were significantly associated with MetS using all five definitions of MetS. In addition, PAD was associated with all five MetS definitions in men, but not in women. Only hyperglycemia and BMI were significantly associated with PAD in women.ConclusionsIn this rural Chinese population, the JIS, IDF and CDS criteria may not be more suitable than WHO and updated NCEP-ATPIII definitions for screening high-risk individuals and estimating the risk of CHD and stroke from MetS, especially in men.     

Low Testosterone Concentrations in Men Contribute to the Gender Gap in Cardiovascular Morbidity and Mortality

BackgroundAcross the industrialized world, men experience an earlier onset of cardiovascular disease (CVD) and a life expectancy 5 to 10 years shorter than women. Low total testosterone (TT) concentrations in men have been suggested as a novel CVD risk factor, but its contribution to this gender gap is less well studied.MethodsWe used data of 4152 individuals (2113 women and 2039 men) aged 20 to 79 years from the longitudinal population-based cohort Study of Health in Pomerania, Germany. Multivariable Poisson and Cox proportional hazard regression models were used to investigate the risk of incident cardiovascular morbidity (5-year examination follow-up), as well as all-cause and CVD mortality (10-year follow-up) between men and women. Additionally, the added risk attributable to low TT in men (<10th percentile) was assessed.ResultsCompared with women, men were uniformly at higher risk of incident cardiovascular morbidity, including overweight, hypertension, dyslipidemia, metabolic syndrome, and type 2 diabetes mellitus. Men were also at increased all-cause mortality (hazard ratio = 2.05; 95% CI, 1.61–2.60) and 10-year CVD risk compared with women. In subgroup analyses, men with low TT showed the highest 10-year CVD and mortality risk compared with both men with higher TT and women. TT was also negatively associated with cardiovascular risk as defined by the Framingham risk score (P < 0.001), after multivariable adjustment.ConclusionsAnalyzing a large population-based sample, we observed that men have a generally higher risk of incident cardiovascular morbidity and mortality. Furthermore, men with low TT concentrations were identified as high-risk individuals with regard to 10-year CVD and mortality risk.     

Prevalence and associated factors of overweight and obesity in a Chinese rural population

Background: Overweight and obesity are now considered as a serious health problem, and a very important risk factor for many diseases. Objective: This study was designed to investigate the epidemiologic features of overweight and obesity among rural adults in China. Method and Procedures: A cross‐sectional survey was conducted during 2004–2005, using a multistage cluster sampling method to select a representative sample in Fuxin county, Liaoning province, China. A total of 29,970 adults, aged ≥35 years, were examined. At baseline, lifestyle and other factors were obtained. Overweight and obesity were defined according to the classification by the World Health Organization. Results: Overall, the prevalence of overweight was 18.6%; 15.1% in men and 22.1% in women. The prevalence of obesity was 1.7%; 1.2% in men and 2.2% in women. Multivariable logistic regression revealed certain risk factors of obesity that included being a women, Mongolian nationality and education status of over junior high school level. Moderate physical activity alone was shown as protective factor. Discussion: Although the prevalence of obesity was low, overweight was relatively high in the Chinese rural population, especially in adult women. Gender, diet, physical activity, education levels, and ethnicity were associated with the prevalence of these health conditions.     

Uric Acid as a Risk Factor for Cardiovascular Disease and Mortality in Overweight/Obese Individuals

Background

The predictive value of serum uric acid (SUA) for adverse cardiovascular events among obese and overweight patients is not known, but potentially important because of the relation between hyperuricaemia and obesity.

Methods

The relationship between SUA and risk of cardiovascular adverse outcomes (nonfatal myocardial infarction, nonfatal stroke, resuscitated cardiac arrest or cardiovascular death) and all-cause mortality, respectively, was evaluated in a post-hoc analysis of the Sibutramine Cardiovascular OUTcomes (SCOUT) trial. Participants enrolled in SCOUT were obese or overweight with pre-existing diabetes and/or cardiovascular disease (CVD). Cox models were used to assess the role of SUA as an independent risk factor.

Results

9742 subjects were included in the study; 83.6% had diabetes, and 75.1% had CVD. During an average follow-up time of 4.2 years, 1043 subjects had a primary outcome (myocardial infarction, resuscitated cardiac arrest, stroke, or cardiovascular death), and 816 died. In a univariate Cox model, the highest SUA quartile was associated with an increased risk of cardiovascular adverse outcomes compared with the lowest SUA quartile in women (hazard ratio [HR]: 1.59; 95% confidence interval [CI]: 1.20–2.10). In multivariate analyses, adjusting for known cardiovascular risk factors the increased risk for the highest SUA quartile was no longer statistically significant among women (HR: 0.99; 95% CI: 0.72–1.36) nor was it among men. Analyses of all-cause mortality found an interaction between sex and SUA. In a multivariate Cox model including women only, the highest SUA quartile was associated with an increased risk in all-cause mortality compared to the lowest SUA quartile (HR: 1.51; 95% CI: 1.08–2.12). No relationship was observed in men (HR: 1.06; 95% CI: 0.82–1.36).

Conclusion

SUA was not an independent predictor of cardiovascular disease and death in these high-risk overweight/obese people. However, our results suggested that SUA was an independent predictor of all-cause mortality in women.     

Excess Cardiovascular Risk Burden in Jamaican Women Does Not Influence Predicted 10-Year CVD Risk Profiles of Jamaica Adults: An Analysis of the 2007/08 Jamaica Health and Lifestyle Survey

Background

Black Caribbean women have a higher burden of cardiovascular disease (CVD) risk factors than their male counterparts. Whether this results in a difference in incident cardiovascular events is unknown. The aim of this study was to estimate the 10 year World Health Organization/International Society for Hypertension (WHO/ISH) CVD risk score for Jamaica and explore the effect of sex as well as obesity, physical activity and socioeconomic status on these estimates.

Methods and Findings

Data from 40–74 year old participants in the 2007/08 Jamaica Health and Lifestyle Survey were used. Trained interviewers administered questionnaires and measured anthropometrics, blood pressure, fasting glucose and cholesterol. Education and occupation were used to assess socioeconomic status. The Americas B tables were used to estimate the WHO/ISH 10 year CVD risk scores for the population. Weighted prevalence estimates were calculated. Data from 1,432 (450 men, 982 women) participants were analysed, after excluding those with self-reported heart attack and stroke. The women had a higher prevalence of diabetes (19%W;12%M), hypertension (49%W;47%M), hypercholesterolemia (25%W;11%M), obesity (46%W;15%M) and physical inactivity (59%W;29%M). More men smoked (6%W;31%M). There was good agreement between the 10-year cardiovascular risk estimates whether or not cholesterol measurements were utilized for calculation (kappa –0.61). While 90% had a 10 year WHO/ISH CVD risk of less than 10%, approximately 2% of the population or 14,000 persons had a 10 year WHO/ISH CVD risk of ≥30%. As expected CVD risk increased with age but there was no sex difference in CVD risk distribution despite women having a greater risk factor burden. Women with low socioeconomic status had the most adverse CVD risk profile.

Conclusion

Despite women having a higher prevalence of CVD risk factors there was no sex difference in 10-year WHO/ISH CVD risk in Jamaican adults.     

Prevalence and risk factors of overweight and obesity in China

Objective: To examine the prevalence and risk factors of overweight and obesity in China. Research Methods and Procedures: A cross‐sectional survey was conducted in a nationally representative sample of 15,540 Chinese adults in 2000–2001. Body weight, height, and waist circumference were measured by trained observers. Overweight and obesity were defined according to the World Health Organization classification. Central obesity was defined according to guidelines of the International Diabetes Federation. Results: Mean BMI and waist circumference were 23.1 kg/m² and 79.6 cm, respectively, for men and 23.5 kg/m² and 77.2 cm, respectively, for women. The prevalences of overweight and obesity were 24.1% and 2.8% in men and 26.1% and 5.0% in women, respectively. The prevalence of central obesity was 16.1% in men and 37.6% in women. The prevalences of overweight, obesity, and central obesity were higher among residents in northern China compared with their counterparts in southern China and among those in urban areas compared with those in rural areas. Lifestyle factors were the most important risk factors to explain the differences in overweight and central obesity between northern and southern residents. Among women, lifestyle and diet were the most important risk factors to explain the differences between urban and rural residents, whereas socioeconomic status, lifestyle, and diet were all important among men. Discussion: Our study indicates that overweight and obesity have become important public health problems in China. Environmental risk factors may be the main reason for regional differences in the prevalence of overweight and obesity in China.     

Do changes in cardiovascular risk factors explain changes in mortality from stroke in Finland?

OBJECTIVES--To estimate the extent to which the changes in the main cardiovascular risk factors (blood pressure, smoking, and serum cholesterol concentration) can explain the observed changes in mortality from stroke in Finland during the past 20 years. DESIGN--Predicted changes in mortality from cerebrovascular disease mortality were calculated by a proportional hazards model from data obtained in cross sectional population surveys in 1972, 1977, 1982, 1987, and 1992. Predicted changes were compared with the observed changes in mortality statistics. SETTING--North Karelia and Kuopio provinces, Finland. SUBJECTS--16,741 men and 16,389 women aged 30-59 randomly selected from the national population register, of whom 14,054 men and 14,546 women participated. MAIN OUTCOME MEASURES--Levels of risk factors and predicted and observed changes in mortality from cerebrovascular disease. RESULTS--The observed changes in diastolic blood pressure, total serum cholesterol concentration, and smoking in the population from 1972 to 1992 predicted a 44% fall in mortality from stroke in men and changes in diastolic blood pressure and smoking predicted a 34% fall in women. The observed fall in mortality from stroke was 66% in men and 60% in women. CONCLUSIONS--Two thirds of the fall in mortality from stroke in men and half in women can be explained by changes in the three main cardiovascular risk factors.     

Aspirin use and chronic diseases: a cohort study of the elderly.

OBJECTIVE--To evaluate the associations between the use of aspirin and the incidences of cardiovascular diseases, cancers, and other chronic diseases. DESIGN--Postal questionnaire survey to elicit details of aspirin use. SETTING--Californian retirement community. SUBJECTS--All 22,781 residents of the community (white, affluent, and well educated) were sent a questionnaire that included questions on medical history and the use of drugs such as analgesics, laxatives, and vitamin supplements. In all 61% responded (13,987, 8881 women and 5106 men; median age 73). They formed the cohort that was followed up for 6 1/2 years using discharge summaries from three hospitals serving the area and death certificates from the health department. Only 13 respondents were lost to follow up but seemed not to have died. MAIN OUTCOME MEASURES--Incidences of cardiovascular diseases, cancers, gastrointestinal bleeding, ulcers, and cataracts were compared in participants who did and did not take aspirin daily. RESULTS--Age adjusted incidences were computed with an internal standard and five age groups. By 1 January 1988 there had been 25 incident cases of kidney cancer among all participants; 341 incident cases of stroke, 253 of acute myocardial infarction, 220 of ischaemic heart disease, and 317 of other heart disease were reported among respondents without a reported history of angina, myocardial infarction, or stroke. The incidence of kidney cancer was raised among those who took aspirin daily compared with those who did not take it, although the increase was significant only in men (relative risks = 6.3, 95% confidence interval 2.2 to 17, for men and 2.1, 0.53 to 8.5, for women). Those who took aspirin daily showed no increased risk of any other cancer, except colon cancer for both sexes combined (relative risk = 1.5, 1.1 to 2.2). The risk of acute myocardial infarction was reduced slightly among regular users of aspirin in men but not women. The risk of ischaemic heart disease was almost doubled in those who took aspirin daily compared with non-users (relative risks = 1.9, 1.1 to 3.1, for men and 1.7, 1.1 to 2.7, for women). Small, non-significant increased risks of stroke were observed in both sexes. CONCLUSION--The daily use of aspirin increased the risk of kidney cancer and ischaemic heart disease.     

Increased Medical Costs in Elders With the Metabolic Syndrome are Most Evident With Hospitalization of Men

BackgroundLittle is known about health care costs associated with the metabolic syndrome (MetS).ObjectiveWe assessed annualized health care costs and health outcomes for both genders in different health care settings among representative Taiwanese elders.MethodsThe Nutrition and Health Survey in Taiwan (1999–2000) provided 1378 individuals aged 65 years or older with known MetS status. Nutrition and Health Survey in Taiwan files were linked to National Health Insurance records (1999–2006). Student t tests and multiple regression models were used to assess expenditures in total and in 6 services: inpatient, ambulatory care, dental care, traditional Chinese medicine, emergency care, and contracted pharmacy. The Cox model was used to assess gender effect on all-cause mortality and cardiovascular disease mortality, whereas logistic regression was used for that on cardiovascular disease hospitalization. The 5 MetS component costs were evaluated by multiple regressions.ResultsMetS affected 29% of men and 48% of women. After full adjustment, those with MetS had 1.30 (95% CI, 1.11–1.52), men had 1.43 (95% CI, 1.20–1.70), and women had 1.19 (95% CI, 0.93–1.52) times higher costs than those without MetS. Compared with no MetS, MetS costs were increased 2.94-fold for inpatient care (95% CI, 1.23–7.10) and 1.30-fold for ambulatory care for men (95% CI, 1.12–1.52), whereas ambulatory MetS costs were increased 1.28-fold for women (95% CI, 1.05–1.57). MetS was associated with higher risk of cardiovascular disease hospitalization in men (adjusted odds ratio, 1.76; 95% CI, 1.20–2.58) but not in women (adjusted odds ratio, 1.08; 95% CI, 0.67–1.75). Among those with MetS, all-cause and cardiovascular mortality were comparable between men and women. Of the MetS components, low HDL cholesterol had the greatest affect on costs, more so in men (2.23-fold) than women (1.58-fold).ConclusionsIn people with MetS, service costs were greater overall, significantly for men, but not women, and these increased costs were evident for men who experienced hospitalization, but not women. At the same time, cardiovascular and all-cause mortalities were not significantly different by gender in regard to MetS in Taiwanese elders.     

Female survival advantage relates to male inferiority rather than female superiority: A hypothesis based on the impact of age and stroke severity on 1-week to 1-year case fatality in 40,155 men and women

Background: It is generally believed that differences in age, stroke characteristics, and cardiovascular risk factors account for observed sex-specific differences in stroke survival.Objectives: We aimed to study female stroke survival advantage before and after the average age of menopause, and whether female survival advantage applies only to patients for whom stroke is the most likely cause of death.Methods: The Danish National Indicator Project, a registry designed to list all hospitalized stroke patients in Denmark beginning in March 2001, had 40,155 registered patients as of February 2007. All registered patients had undergone evaluation including stroke severity (as measured by the Scandinavian Stroke Scale [SSS], using a total score of 0–58, in which lower scores indicate more severe strokes), computed tomography, and cardiovascular risk factors. Patients were followed from admission until death or censoring. Case fatality (stratified by 1 week, 1 month, 3 months, and 1 year) in men and women was correlated with age and stroke severity. Adjustment for cardiovascular risk factors was performed by means of multivariate regression analysis.Results: A total of 20,854 (51.9%) men and 19,301 (48.1%) women were registered. Women were significantly older than men at the time of stroke (74.5 vs 69.7 years, respectively; P < 0.001) and had signficantly more severe strokes, as expressed by the mean SSS score (39.6 vs 43.3; P < 0.001). Stratification of 1-week to 1-year case fatality according to age and stroke severity indicated that women survived significantly better than men from the mid-fifties onward, when controlling for age, stroke severity, and cardiovascular risk factor profile. The observed female survival advantage increased with age. The female survival advantage was seen in patients with severe as well as mild strokes, but not in those younger than age 50 years.Conclusions: Our findings dispute the effects of female sex hormones as the underlying cause of female survival superiority over men. Instead, we propose the hypothesis that the progressive deficiency of male sex hormones (testosterone), beginning in men in middle age, is the underlying cause of the gap in survival rates between men and women. Accordingly, the female survival advantage is rooted in male inferiority rather than innate female superiority.     

Alternative hormone replacement regimens: is there a need for further clinical trials?

PURPOSE OF REVIEW: To review the randomized trials of hormone replacement therapy. RECENT FINDINGS: Studies have shown that conjugated equine estrogen 0.625 mg a day plus medroxyprogesterone acetate 2.5 mg a day increased the risk of cardiovascular events during the first year of treatment in women both with and without coronary heart disease. Conjugated equine estrogen plus medroxyprogesterone acetate also increased the overall risk of myocardial infarction and stroke in women without coronary heart disease, and myocardial infarction or death in women with coronary heart disease, and also increased the risk of breast cancer, cognitive decline and dementia. Unopposed, oral 17B-estradiol increased the risk of stroke during the first 6 months of treatment in women with a previous stroke. Oral 17B-estradiol with or without cyclic progestin had no effect on the progression of atherosclerosis or reinfarction. Transdermal 17B-estradiol plus cyclic progestin was associated with a non-significant increase in coronary heart disease events in women with coronary heart disease. Compared with placebo, cardiovascular events increased in the ongoing estrogen-only arm of the Women's Health Initiative, indicating that unopposed conjugated equine estrogen is unlikely to be cardioprotective. However, oral 17B-estradiol retarded the progression of subclinical atherosclerosis in younger women without coronary heart disease. SUMMARY: Hormone replacement therapy should not be initiated for the primary or secondary prevention of coronary heart disease in women. A trial of 17B-estradiol started at menopause in women without coronary heart disease should be considered.     

Impact of treating hyperlipidemia or hypertension to reduce the risk of death from coronary artery disease

OBJECTIVE: To compare the prevalence of modifiable risk factors for cardiovascular disease among hypertensive and nonhypertensive adults and to estimate the effect of treating hyperlipidemia or hypertension to reduce the risk of death from coronary artery disease. METHODS: The authors evaluated a sample of 7814 subjects aged 35-74 years free of clinical cardiovascular disease from the Canadian Heart Health Surveys to estimate the prevalence of cardiovascular risk factors. They identified hyperlipidemic subjects (ratio of total cholesterol to high-density lipoprotein cholesterol [total-C/HDL-C] 6.0 [corrected] or more for men and 5.0 [corrected] or more for women) and hypertensive subjects (systolic or diastolic blood pressure 160/90 mm Hg or greater, or receiving pharmacologic or nonpharmacologic treatment). A life expectancy model was used to estimate the rate of death from coronary artery disease following specific treatments. RESULTS: An elevated total-C/HDL-C ratio was significantly more common among hypertensive than nonhypertensive men aged 35-64 (rate ratio [RR] 1.56 for age 35-54, 1.28 for age 55-64) and among hypertensive than nonhypertensive women of all ages (RR 2.73 for age 35-54, 1.58 for age 55-64, 1.31 for age 65-74). Obesity and a sedentary lifestyle were also more common among hypertensive than among nonhypertensive subjects. According to the model, more deaths from coronary artery disease could be prevented among subjects with treated but uncontrolled hypertension by modifying lipids rather than by further reducing blood pressure for men aged 35-54 (reduction of 50 v. 29 deaths per 100,000) and 55-64 (reduction of 171 v. 104 deaths per 100,000) and for women aged 35-54 (reduction of 44 v. 39 deaths per 100,000). Starting antihypertensive therapy in subjects aged 35-74 with untreated hypertension would achieve a greater net reduction in deaths from coronary artery disease than would lipid lowering. Nonetheless, the benefits of lipid therapy were substantial: lipid intervention among hypertensive subjects aged 35-74 represented 36% of the total benefits of treating hyperlipidemia in the total hyperlipidemic population. INTERPRETATION: The clustering of hyperlipidemia and the potential benefits of treatment among hypertensive adults demonstrate the need for screening and treating other cardiovascular risk factors beyond simply controlling blood pressure.     

Predicting Stroke Risk Based on Health Behaviours: Development of the Stroke Population Risk Tool (SPoRT)

Background

Health behaviours, important factors in cardiovascular disease, are increasingly a focus of prevention. We appraised whether stroke risk can be accurately assessed using self-reported information focused on health behaviours.

Methods

Behavioural, sociodemographic and other risk factors were assessed in a population-based survey of 82 259 Ontarians who were followed for a median of 8.6 years (688 000 person-years follow-up) starting in 2001. Predictive algorithms for 5-year incident stroke resulting in hospitalization were created and then validated in a similar 2007 survey of 28 605 respondents (median 4.2 years follow-up).

Results

We observed 3 236 incident stroke events (1 551 resulting in hospitalization; 1 685 in the community setting without hospital admission). The final algorithms were discriminating (C-stat: 0.85, men; 0.87, women) and well-calibrated (in 65 of 67 subgroups for men; 61 of 65 for women). An index was developed to summarize cumulative relative risk of incident stroke from health behaviours and stress. For men, each point on the index corresponded to a 12% relative risk increase (180% risk difference, lowest (0) to highest (9) scores). For women, each point corresponded to a 14% relative risk increase (340% difference, lowest (0) to highest (11) scores). Algorithms for secondary stroke outcomes (stroke resulting in death; classified as ischemic; excluding transient ischemic attack; and in the community setting) had similar health behaviour risk hazards.

Conclusion

Incident stroke can be accurately predicted using self-reported information focused on health behaviours. Risk assessment can be performed with population health surveys to support population health planning or outside of clinical settings to support patient-focused prevention.     

Coffee consumption and death from coronary heart disease in middle aged Norwegian men and women.

OBJECTIVE--To study the association between number of cups of coffee consumed per day and coronary death when taking other major coronary risk factors into account. DESIGN--Men and women attending screening and followed up for a mean of 6.4 years. SETTING--Cardiovascular survey performed by ambulatory teams from the National Health Screening Service in Norway. PARTICIPANTS--All middle aged people in three counties: 19,398 men and 19,166 women aged 35-54 years who reported neither cardiovascular disease or diabetes nor symptoms of angina pectoris or intermittent claudication. MAIN OUTCOME MEASURE--Predictive value of number of cups of coffee consumed per day. RESULTS--At initial screening total serum cholesterol concentration, high density lipoprotein cholesterol concentration, blood pressure, height, and weight were measured and self reported information about smoking history, physical activity, and coffee drinking habits was recorded. Altogether 168 men and 16 women died of coronary heart disease during follow up. Mean cholesterol concentrations for men and women were almost identical and increased from the lowest to highest coffee consumption group (13.1% and 10.9% respectively). With the proportional hazards model and adjustment for age, total serum and high density lipoprotein cholesterol concentrations, systolic blood pressure, and number of cigarettes per day the coefficient for coffee corresponded to a relative risk between nine or more cups of coffee and less than one cup of 2.2 (95% confidence interval 1.1 to 4.5) for men and 5.1 (0.4 to 60.3) for women. For men the relative risk varied among the three counties. CONCLUSIONS--Coffee may affect mortality from coronary heart disease over and above its effect in raising cholesterol concentrations.     

Cardiovascular Disease Risk of Abdominal Obesity vs. Metabolic Abnormalities

It remains unclear whether abdominal obesity increases cardiovascular disease (CVD) risk independent of the metabolic abnormalities that often accompany it. Therefore, the objective of this study was to evaluate the independent effects of abdominal obesity vs. metabolic syndrome and diabetes on the risk for incident coronary heart disease (CHD) and stroke. The Framingham Offspring, Atherosclerosis Risk in Communities, and Cardiovascular Health studies were pooled to assess the independent effects of abdominal obesity (waist circumference >102 cm for men and >88 cm for women) vs. metabolic syndrome (excluding the waist circumference criterion) and diabetes on risk for incident CHD and stroke in 20,298 men and women aged ≥45 years. The average follow‐up was 8.3 (s.d. 1.9) years. There were 1,766 CVD events. After adjustment for demographic factors, smoking, alcohol intake, number of metabolic syndrome components, and diabetes, abdominal obesity was not significantly associated with an increased risk of CVD (hazard ratio (HR) (95% confidence interval): 1.09 (0.98, 1.20)). However, after adjustment for demographics, smoking, alcohol intake, and abdominal obesity, having 1–2 metabolic syndrome components, the metabolic syndrome and diabetes were each associated with a significantly increased risk of CVD (2.12 (1.80, 2.50), 2.82 (1.92, 4.12), and 5.33 (3.37, 8.41), respectively). Although abdominal obesity is an important clinical tool for identification of individuals likely to possess metabolic abnormalities, these data suggest that the metabolic syndrome and diabetes are considerably more important prognostic indicators of CVD risk.     

Calcium Intake and Serum Concentration in Relation to Risk of Cardiovascular Death in NHANES III

Background

Evidence for an association between calcium intake and risk of cardiovascular death remains controversial. By assessing dietary intake, use of supplements, and serum levels of calcium, we aimed to disentangle this link in the third National Health and Nutrition Examination Survey (NHANES III).

Methods

Mortality linkage of NHANES III to death certificate data for those aged 17 years or older (n = 20,024) was used to estimate risk of overall cardiovascular death as well as death from ischemic heart disease (IHD), acute myocardial infarction (AMI), heart failure (HF), and cerebrovascular disease (CD) with multivariate Cox proportional hazards regression analysis.

Results

About 10.0% of the population died of cardiovascular disease and the majority (5.4%) died of IHD. There was increased risk of overall CVD death for those in the bottom 5% of serum calcium compared to those in the mid 90% (HR: 1.51 (95% CI: 1.03–2.22)). For women there was a statistically significant increased risk of IHD death for those with serum calcium levels in the top 5% compared to those in the mid 90% (HR: 1.72 (95%CI: 1.13–2.61)), whereas in men, low serum calcium was related to increased IHD mortality (HR: 2.32 (95% CI 1.14–3.01), P_interaction: 0.306). No clear association with CVD death was observed for dietary or supplemental calcium intake.

Conclusions

Calcium as assessed by serum concentrations is involved in cardiovascular health, though differential effects by sex may exist. No clear evidence was found for an association between dietary or supplementary intake of calcium and cardiovascular death.     

Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study.

OBJECTIVE: To determine whether a low ankle brachial pressure index is associated with an increased risk of cardiovascular events and death, and whether the prediction of such events could be improved by including this index. DESIGN: Cohort study. SETTING: 11 practices in Edinburgh, Scotland. SUBJECTS: 1592 men and women aged 55-74 years selected at random from the age-sex registers of 11 general practices and followed up for 5 years. MAIN OUTCOME MEASURES: Incidence of fatal and non-fatal cardiovascular events and all cause mortality. RESULTS: At baseline 90 (5.7%) of subjects had an ankle brachial pressure index < or = 0.7, 288 (18.2%) had an index < or = 0.9, and 566 (35.6%) < or = 1.0. After five years subjects with an index < or = 0.9 at baseline had an increased risk of non-fatal myocardial infarction (relative risk 1.38, 95% confidence interval 0.88 to 2.16), stroke (1.98, 1.05 to 3.77), cardiovascular death (1.85, 1.15 to 2.97), and all cause mortality (1.58, 1.14 to 2.18) after adjustment for age, sex, coronary disease, and diabetes at baseline. The ability to predict subsequent events was greatly increased by combining the index with other risk factors--for example, hypertensive smokers with normal cholesterol concentrations had a positive predictive value of 25.0%, increasing to 43.8% in subjects with a low index and decreasing to 15.6% in those with a normal index. CONCLUSION: The ankle brachial pressure index is a good predictor of subsequent cardiovascular events, and improves on predictions by conventional risk factors alone. It is simple and accurate and could be included in routine screening of cardiovascular status.