Risk factors for stroke in middle aged British men.

OBJECTIVE--To determine the risk factors for stroke in a cohort representative of middle aged British men. DESIGN--Prospective study of a cohort of men followed up for eight years. SETTING--General practices in 24 towns in England, Wales, and Scotland (the British regional heart study). SUBJECTS--7735 men aged 40-59 at screening, selected at random from one general practice in each town. MAIN OUTCOME MEASURE--Fatal and non-fatal strokes. RESULTS--110 of the men had at least one stroke; there were four times as many non-fatal as fatal strokes. The relative risk of stroke was 12.1 in men who had high blood pressure (systolic blood pressure greater than or equal to 160 mm Hg) and were current smokers compared with normotensive, non-smoking men. Diastolic blood pressure yielded no additional information, and former cigarette smokers had the same risk as men who had never smoked. Heavy alcohol intake was associated with a relative risk of stroke of 3.8 in men without previously diagnosed cardiovascular disease. Men with pre-existing ischaemic heart disease had an increased risk of stroke, but only when left ventricular hypertrophy on electrocardiography was also present. CONCLUSIONS--Systolic blood pressure, cigarette smoking, and left ventricular hypertrophy on electrocardiography in men with pre-existing ischaemic heart disease were found to be the major risk factors for stroke in middle aged British men. Heavy alcohol intake seemed to increase the risk of stroke in men without previously diagnosed cardiovascular disease. A large proportion of strokes should be preventable by controlling blood pressure and stopping smoking.     

Risk factors for premature death in middle aged men

The causes of premature death and the associated risk factors were analysed in a cohort of 7935 middle aged men participating in a preventive population programme in Malmö. They were screened when aged 46-48 and then followed up for 3½-8 years. Two hundred and eighteen died, of whom 181 (83%) underwent necropsy. Three major causes of death were established: cancer in 61 (28%), deaths related to consumption of alcohol in 55 (25%), and coronary heart disease in 50 (23%).Distinctly different patterns of risk factors were found to be associated with each of the three main causes of premature death. In death due to coronary heart disease smoking (p=0·0062), serum cholesterol concentration (p=0·00014), serum triglyceride concentration (p=0·00013), systolic blood pressure (p=0·000012), and diastolic blood pressure (p=0·0021) were the strongest single determinants but diastolic blood pressure ceased to be a predictive factor in a multivariate analysis whereas all the other variables could be combined in a highly predictive logistic model. In death related to consumption of alcohol equal or even stronger associations were found for serum γ glutamyltransferase activity (p<0·0001), points scored in a questionnaire screening for alcoholism (p<0·0001), and, inversely, serum cholesterol (p=0·0046) and serum creatinine (p<0·0001) concentrations both when applied independently and when combined in a logistic model. In death due to cancer significant associations were found for serum urate concentration (p=0·023) and, inversely, serum cholesterol concentration (p=0·056-0·031).Malignant diseases and diseases related to consumption of alcohol were at least as prominent as cardiovascular disorders in causing premature death in the cohort of men studied. All three types of conditions are potentially avoidable and seem to be associated with significant and distinctive patterns of risk factors. These patterns should be used, as blood pressure and serum lipid concentrations already are, to predict the risk of premature death and indicate preventive measures.     

Physical activity and stroke in British middle aged men.

OBJECTIVES--To assess the relation between physical activity and stroke and to determine the overall benefit of physical activity for all major cardiovascular events. DESIGN--Prospective study of a cohort of men followed up for 9.5 years. SETTING--General practices in 24 towns in England, Wales, and Scotland (British regional heart study). SUBJECTS--7735 men aged 40-59 at screening, selected at random from one general practice in each of 24 towns. MAIN OUTCOME MEASURES--Fatal and non-fatal strokes and heart attacks. RESULTS--128 major strokes (fatal and non-fatal) occurred. Physical activity was inversely associated with risk of stroke independent of coronary risk factors, heavy drinking, and pre-existing ischaemic heart disease or stroke (relative risk 1.0 for inactivity, 0.6 moderate activity, and 0.3 vigorous activity; test for trend p = 0.008). The association remained after excluding men reporting regular sporting (vigorous) activity. However, vigorous physical activity was associated with a marginally significant increased risk of heart attack compared with moderate or moderately vigorous activity in men with no pre-existing ischaemic heart disease or stroke (relative risk 1.6%; 95% confidence interval 0.96 to 2.8). In men with symptomatic ischaemic heart disease or stroke those doing moderately vigorous or vigorous activity had a risk of heart attack slightly higher than that in inactive men (relative risk = 1.6; 0.8 to 3.3). CONCLUSIONS--Moderate physical activity significantly reduces the risk of stroke and heart attacks in men both with and without pre-existing ischaemic heart disease. More vigorous activity did not confer any further protection. Moderate activity, such as frequent walking and recreational activity or weekly sporting activity, should be encouraged without restriction.     

Alcohol and ischaemic heart disease in middle aged British men.

The relation between alcohol intake and ischaemic heart disease was examined in a large scale prospective study of middle aged men drawn from general practices in 24 British towns. After an average follow up of 6.2 years 335 of the 7729 men had experienced a myocardial infarction (fatal or non-fatal) or sudden cardiac death. No significant relation was found between reported alcohol intake and the incidence of such events. Though the group of light daily drinkers had the lowest incidence of ischaemic heart disease events, it also contained the lowest proportion of current smokers, had the lowest mean blood pressure, had the lowest mean body mass index, and contained the lowest proportion of manual workers. These characteristics are more likely to account for the apparent protective effect of alcohol against ischaemic heart disease than a direct effect of alcohol. Compared with the effects of established risk factors alcohol seems to be quite unimportant in the development of ischaemic heart disease.     

Sexual behaviour of young and middle aged men in England and Wales.

Establishing patterns of sexual behaviour is essential in predicting the future spread of HIV. The sexual behaviour patterns of a randomly selected sample of 480 white men aged 15 to 49 were obtained by interview and analysed in relation to age, social class, and area of residence. Over half of the men had first had intercourse before the age of 18 and over three quarters had done so before the age of 20. Age at first intercourse tended to be lower in more recent birth cohorts and in social classes III, IV, and V. Men in earlier birth cohorts tended to have had fewer heterosexual partners, both regular and casual, than those born more recently, but there were no social class or regional differences in the number of partners. Eight of the 480 men (1.7%, 95% confidence interval 1.1 to 2.3%) stated that they had had homosexual intercourse, four of whom had had one casual homosexual partner. Only one man had had more than 25 homosexual partners. The number of men having had homosexual intercourse was lower than is widely thought. When possible, data were checked with national data or other surveys and thought to be accurate. The difficulties in collecting data of this nature are discussed.     

Type A behaviour and ischaemic heart disease in middle aged British men.

The Bortner questionnaire, which measures aspects of type A (coronary prone) behaviour was completed by 5936 men aged 40-59 selected at random from one general practice in each of 19 British towns. The presence of ischaemic heart disease was determined at initial examination and the men were followed up for an average of 6.2 years for morbidity and mortality from myocardial infarction and for sudden cardiac death. Non-manual workers had significantly higher scores (more type A) than manual workers and the score decreased (less type A) with increasing age. After adjustment for social class and age men with higher scores had higher prevalences of ischaemic heart disease less marked for electrocardiographic evidence and more marked for response to a chest pain questionnaire (angina or possible myocardial infarction). A man''s recall of a doctor''s diagnosis of ischaemic heart disease, however, did not relate to his Bortner score. There was no significant relation between the Bortner score and the attack rate or incidence of major ischaemic heart disease events. In this study type A behaviour, as measured by the Bortner questionnaire, did not predict major ischaemic heart disease events in British middle aged men.     

Low systolic blood pressure and self perceived wellbeing in middle aged men.

OBJECTIVE--To examine the relation between systolic blood pressure and self perceived wellbeing in 50 year old men. DESIGN--Cross sectional population study of data derived from questionnaires and physical examination as a part of a cardiovascular risk factor survey. SETTING--City of Gothenburg, Sweden. STUDY POPULATION--776 men from a random population sample of 1016 men aged 50. METHODS--Self perceived wellbeing according to the Gothenburg quality of life questionnaire, which is an assessment of social, physical, and mental wellbeing in 15 different areas. MAIN RESULTS--Low systolic blood pressure was significantly (p < 0.05) related to impaired social wellbeing in four areas: work, home and family, financial situation, and housing. Of the items dealing with physical wellbeing, health, memory, and appetite were significantly related to blood pressure. As regards mental wellbeing, energy and self confidence were significantly related to systolic blood pressure. Diastolic blood pressure was significantly related to housing, memory, energy, patience, and self confidence. In multiple regression analyses that controlled for smoking, stress, physical activity, social activity, and emotional support, poor social, physical, and mental wellbeing were all significantly related to low systolic blood pressure independently of other factors. Low diastolic blood pressure was independently associated with poor physical and mental, but not social, wellbeing. CONCLUSION--Low systolic blood pressure was associated with poor perception of wellbeing in several areas. The cause is unclear.     

Body weight and mortality in middle aged British men: impact of smoking.

OBJECTIVE--To assess the relation between body mass index and mortality in middle aged British men. DESIGN--Men who were recruited for the British Regional Heart Study were followed up for a mean of nine years. SETTING--General practices in 24 British towns. SUBJECTS--7735 Men aged 40-59 years selected from the age-sex registers of one group practice in each of the 24 towns. MAIN OUTCOME MEASURE--Mortality from cardiovascular and non-cardiovascular causes. RESULTS--660 Of the men died. There was a U-shaped relation between body mass index and total mortality. Very lean men (less than 20 kg/m2) had by far the highest mortality followed by lean men (20-22 kg/m2) and obese men (greater than or equal to 28 kg/m2). The high mortality in lean and very lean men was due largely to non-cardiovascular causes, particularly lung cancer and respiratory disease, which are associated with cigarette smoking. In obese men deaths were more likely to be due to cardiovascular causes. There was a strong inverse association between body weight and cigarette smoking. When the pattern of mortality was examined by age, smoking habits, and pre-existing smoking related disease both very lean men and obese men consistently had an increased mortality. The U-shaped relation was most prominent in men in the oldest age group (55-59). Current smokers had a higher mortality than former smokers at virtually all values of body mass index. An increased mortality in lean men was seen only in current smokers and in men with smoking related disease. Among men who had never smoked, lean men had the lowest total mortality, thereafter mortality increased with increasing body mass index (p less than 0.01). CONCLUSIONS--This study provides strong evidence of the impact of cigarette smoking on body weight and mortality and strongly suggests that the benefits of giving up smoking are far greater than the problems associated with the increase in weight that may occur.     

Prospective study of risk factors for development of non-insulin dependent diabetes in middle aged British men.

OBJECTIVE--To determine the risk factors for noninsulin dependent diabetes in a cohort representative of middle aged British men. DESIGN--Prospective study. SUBJECTS AND SETTINGS--7735 men aged 40-59, drawn from one group practice in each of 24 towns in Britain. Known and probable cases of diabetes at screening (n = 158) were excluded. MAIN OUTCOME MEASURES--Non-insulin dependent diabetes (doctor diagnosed) over a mean follow up period of 12.8 years. RESULTS--There were 194 new cases of non-insulin dependent diabetes. Body mass index was the dominant risk factor for diabetes, with an age adjusted relative risk (upper fifth to lower fifth) of 11.6; 95% confidence interval 5.4 to 16.8. Men engaged in moderate levels of physical activity had a substantially reduced risk of diabetes, relative to the physically inactive men, after adjustment for age and body mass index (0.4; 0.2 to 0.7), an association which persisted in full multivariate analysis. A nonlinear relation between alcohol intake and diabetes was observed, with the lowest risk among moderate drinkers (16-42 units/week) relative to the baseline group of occasional drinkers (0.6; 0.4 to 1.0). Additional significant predictors of diabetes in multivariate analysis included serum triglyceride concentration, high density lipoprotein cholesterol concentration (inverse association), heart rate, uric acid concentration, and prevalent coronary heart disease. CONCLUSION--These findings emphasise the interrelations between risk factors for non-insulin dependent diabetes and coronary heart disease and the potential value of an integrated approach to the prevention of these conditions based on the prevention of obesity and the promotion of physical activity.     

Cardiovascular system of normal aged subjects. Cardiovascular senescence

The cardiovascular system of the elderly is characterised by (i) an increased characteristic impedance of the big vessels, without hypertension; (ii) a cardiac index unchanged at rest and during submaximal exercising, despite a diminished VO2 max; (iii) a diastolic dysfunction with reduced rapid early filling (E wave at echo) and enhanced atrial systole (A wave); (iv) benign arrhythmias; (v) a reduced coronary reserve and an increased sensitivity to ischemia; (vi) an efficacy of converting enzyme inhibitors remaining unchanged, despite an altered renin-agiotensin system.     

Personal best marathon time and longest training run, not anthropometry, predict performance in recreational 24-hour ultrarunners

In recent studies, a relationship between both low body fat and low thicknesses of selected skinfolds has been demonstrated for running performance of distances from 100 m to the marathon but not in ultramarathon. We investigated the association of anthropometric and training characteristics with race performance in 63 male recreational ultrarunners in a 24-hour run using bi and multivariate analysis. The athletes achieved an average distance of 146.1 (43.1) km. In the bivariate analysis, body mass (r = -0.25), the sum of 9 skinfolds (r = -0.32), the sum of upper body skinfolds (r = -0.34), body fat percentage (r = -0.32), weekly kilometers ran (r = 0.31), longest training session before the 24-hour run (r = 0.56), and personal best marathon time (r = -0.58) were related to race performance. Stepwise multiple regression showed that both the longest training session before the 24-hour run (p = 0.0013) and the personal best marathon time (p = 0.0015) had the best correlation with race performance. Performance in these 24-hour runners may be predicted (r2 = 0.46) by the following equation: Performance in a 24-hour run, km) = 234.7 + 0.481 (longest training session before the 24-hour run, km) - 0.594 (personal best marathon time, minutes). For practical applications, training variables such as volume and intensity were associated with performance but not anthropometric variables. To achieve maximum kilometers in a 24-hour run, recreational ultrarunners should have a personal best marathon time of ～3 hours 20 minutes and complete a long training run of ～60 km before the race, whereas anthropometric characteristics such as low body fat or low skinfold thicknesses showed no association with performance.     

Coronary heart disease and mortality in middle aged men from different occupational classes in Sweden.

In the Gothenburg primary prevention study 7083 middle aged men were classified into five categories by occupational state. A retrospective analysis of the data showed that low occupational class was associated with slight increases in smoking rates, systolic blood pressure, serum cholesterol concentration, body mass index, and heart rate. Alcohol abuse was strongly associated with low occupational class. After a mean of 11.8 years'' follow up the incidence of coronary heart disease was found to be strongly and inversely related to occupational class. For death from coronary heart disease this association fell just below significance when other risk factors were taken into account, but the inverse association between non-fatal myocardial infarction and occupational class persisted even in multivariate analysis. A weak but independent inverse relation was found between occupational class and fatal cancer. Mortality from all causes in the lowest occupational class was 12% compared with 6% in the highest class, and this difference could only partly be explained by other factors. After 10 years a sub-sample of the men were examined again. Risk factors had decreased in all occupational classes, but the changes in risk were not associated with occupational class. Social class, defined by occupation, in Sweden is clearly related to the incidence of coronary heart disease.     

Prospective evaluation of cardiac effects of first-time marathon training,running, and recovery in middle-aged men: cohort study rationale and design

BackgroundSeveral phenomena may point to potentially detrimental cardiac effects of endurance exercise, such as elevated circulating cardiac troponin levels and reductions in systolic and diastolic function directly after marathon completion. Furthermore, while myocardial abnormalities have been reported in patients who recovered from COVID-19, the cardiac impact of extensive endurance exercise in individuals who recovered from COVID-19 remains unknown. We therefore aim to investigate (potentially detrimental) cardiac effects of first-time marathon training and participation, including a subset of participants who recovered from COVID-19, in apparently healthy middle-aged men.Study designThis exploratory prospective cohort study investigates cardiac effects of first-time marathon running in 24 middle-aged (35–50 years) healthy men. Primary outcomes are cardiac morphological changes from pre-training up to 1 month after marathon completion, measured with magnetic resonance imaging (MRI) at 4 time points: 1) baseline (4 months before the marathon), 2) pre-marathon (2 weeks before the marathon), 3) post-marathon (< 24 h post-marathon), and 4) recovery (4 weeks after the marathon). Secondary parameters include other cardiac or non-cardiac changes: 1) quantitative MRI myocardial mapping, including mean diffusivity and extracellular volume fraction, 2) echocardiographic morphology and function changes, 3) VO₂max, 4) electrocardiogram changes, and 5) levels of cardiac biomarkers.DiscussionThis study will contribute to our understanding of cardiac adaptations and maladaptations to first-time marathon running in middle-aged men, and the interaction between extreme endurance exercise and potential detrimental cardiac effects, also in the context of COVID-19. Results will inform on future research directions while providing new clinical insights for health professionals involved in athlete care.     

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.