Category Archive for: ‘Coronary heart disease’
Large differences in global CHD risk within Europe
A re-analysis of the 10-year follow-up data of the SCS published in 2000 showed large differences between northern and southern Europe in the number of hard CHD events at the same level of the major risk factors serum cholesterol, blood pressure and smoking. The number of hard CHD events was 3 times higher in northern Europe compared to southern Europe. In the early 1970s Ancel Keys and colleagues published the finding that at the same level of the major risk factors the number of hard CHD events after 5 years of follow-up was twice as great in the US railroad cohort as in the European cohorts.
Implications of differences in global risk for prevention and treatment
It took decades of observational epidemiology and clinical trials before the importance of the global CHD risk concept was accepted by the medical profession. If the level of absolute risk is crucial for taking action, an integrated approach is needed to lower global risk in both cardiac patients and in high-risk persons. The country differences in absolute risk indicate that greater intensity of interventions is required in regions such as northern Europe.
High blood pressure and smoking were risk factors for three major CVDs while serum cholesterol predicted only CHD
Blood pressure and cigarette smoking predicted overall cardiovascular disease mortality and each major individual cardiovascular disease: that is, coronary heart disease, other heart disease and stroke. Serum cholesterol predicted cardiovascular and coronary heart disease mortality. The association of serum cholesterol with cardiovascular mortality is due to its strong relation to coronary heart disease deaths.
Different cardiovascular diseases
The most common cardiovascular diseases are coronary heart disease, other heart disease, and stroke. In the SCS, coronary heart disease mortality included fatal myocardial infarction and sudden death of probable coronary origin. Mortality from other heart disease, also called atypical coronary heart disease, consists of chronic heart failure and chronic arrhythmias, mostly atrial fibrillation. Mortality from stroke includes both thrombotic and hemorrhagic stroke, which were inseparable under the conditions of these surveys.
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A healthful diet and lifestyle is related to low CVD risk
A Mediterranean style diet, a high level of physical activity, not smoking and moderate alcohol consumption were all associated with low 10-year risk of CHD and CVD in the European HALE project. A very low risk of these diseases was observed in elderly men who had four compared to those who had none or one healthful diet and lifestyle factor. We estimate that among elderly men who did not adhere to a low-risk lifestyle pattern, 64% of deaths due to CHD and 61% due to CVD might have been prevented based on the observed risk differences.
Among elderly men, the more healthful factors of diet and lifestyle the lower the CVD mortality observed. More than 60% of CVD mortality was associated with lack of adherence to the low-risk pattern. This finding implies that even at advanced ages those who follow a Mediterranean style diet and maintain a healthful lifestyle are less likely to die from CVD.
High optimism low CVD mortality
Optimism was a relatively stable trait over 15 years in the Zutphen Elderly Study. Elderly men with a high level of optimism had only half the risk of 15-year CVD mortality compared to those with a low level of optimism. Similar results were obtained after adjustment for CVD risk factors, lifestyle factors, living arrangements, self-rated health and depressive symptoms.
Optimism was not related to major cardiovascular risk factors. However, a high level of optimism was associated with better coping behavior, goal-directed efforts such as better self-care, vitality, emotional flexibility and seeking social support. Optimism was also related to physical activity, non-smoking, moderate alcohol intake and higher intakes of fruit, vegetables and whole-grain bread. This suggests that a high level of optimism affects the risk of cardiovascular death through positive psycho-social behaviors, more healthy lifestyle and dietary habits.
Flavan-3-ol intake related to CHD but not to stroke
An average intake of monomeric flavan-3-ols of 124 mg/d, compared to an average intake of 25 mg/d, was associated with a 51% lower 10-year CHD mortality in the Zutphen Elderly Study. Tea is a rich source of both flavan-3-ols and flavonols. Therefore we analyzed also the intake of tea, flavan-3-ols not from tea and flavonols not from tea in relation to fatal CHD. Tea and flavan-3-ols not from tea were inversely related to fatal CHD but flavonols from other sources than tea were not associated. These results suggest that a high intake of flavan-3-ols is related to a low risk of fatal CHD independent of flavonols. In contrast, flavan-3-ols intake was not associated with 10-year stroke incidence.
Measuring flavan-3-ols (catechins)
Flavan-3-ols are a subclass of flavonoids, an extended class of chemically related compounds ubiquitously present in plant foods. Evidence from controlled experiments in people shows that one of the flavan-3-ols, epicatechin, has favorable effects on endothelial function, blood pressure and insulin resistance. The richest sources of flavan-3-ols are tea, apples and chocolate (cocoa).
Chronic diseases associated with all-cause mortality
In middle-aged men from the Seven Countries Study the additional relative risk of death within 15 years varied for seven chronic diseases from 47% for ‘other’ heart disease to 81% for heart attacks.
In older men the additional risk of death for any chronic disease was 95% in Finland, 88% in The Netherlands and 27% in Italy.
The risk of death with an entry class of 3 or more chronic diseases compared to their absence was more than 3 times greater in elderly men from Finland and The Netherlands and 2 times greater in Italy.
These results indicate that the presence of clinically manifest major chronic diseases predicts all-cause mortality and the relation is stronger in northern than in southern Europe.
The scrutinized diseases were heart attack, heart failure, stroke, peripheral arterial disease, other heart disease, diabetes and chronic obstructive pulmonary disease.
Depression and physical inactivity, two sides of the same coin?
The relationship between depressive symptoms and CVD risk may be the consequence of a more sedentary lifestyle of depressed persons. Thus, physical inactivity may be the intermediate factor in the relation between depressive symptoms and CVD. The independent and combined effects of depressive symptoms and physical activity on CVD mortality were investigated prospectively in elderly men from the FINE study cohorts of Finland, the Netherlands and Italy.
Physical inactivity and depression both related to cardiovascular risk.
A 30 min/d lower level of physical activity at entry was associated with a 9% excess CVD mortality after 10 years. A one-standard deviation greater score for depressive symptoms was related to a 37% higher CVD mortality, after adjustment for physical activity. The excess risk of CVD mortality attributable to the combined effect of depressive symptoms with inactivity was 47%. The greater risk of CVD due to depressive symptoms cannot be explained by physical inactivity. However, depressive symptoms and physical inactivity may interact to increase CVD risk.
Cardiovascular risk factors also associated with dementia
The risk factors – smoking, serum cholesterol, blood pressure, lung function and the presence of CVD at baseline – were associated with death from dementia. The risk was 58% greater for heavy compared to non-smokers, 55% greater for hypertensives compared to those with normal blood pressure, 73% greater for those with a high level of serum cholesterol, 46% lower for those with a high compared to a low lung function and 94% greater for those with a history of CVD at baseline compared to those with no such history. Men with a combination of two of the risk factors had a 2 times greater risk of death from dementia. These results suggest that that cardiovascular risk factors measured in midlife predict the risk of death with dementia.
Cardiovascular risk factors measured in the Seven Countries Study
Cardiovascular risk factors were measured at baseline and 160 out of 10,211 middle-aged men died from dementia during 40 years of follow-up. The results of the SCS suggest that cardiovascular risk factors affect the neurodegenerative process leading to dementia.
The lignan MAT might be inversely related to CHD
The median total lignan intake in elderly men in Zutphen was 977 microgram/d. The intake of the lignan MAT (matairesinol) was significantly inversely related to 15-year fatal CHD – in contrast to the total lignan intake which was unrelated. The inverse association between MAT and CHD mortality could be due to an associated factor such as wine consumption.
How to measure lignans
Lignans are diphenolic compounds present in plant foods (and not to be confused with lignin, one of the dietary fibers). We studied the lignans LARI (lariciresinol), PINO (pinoresinol), SECO (secoisolariciresionol) and MAT. These molecules are converted to enterolignans by the intestinal microflora and possess estrogen-like activities.
We developed a method to measure the four lignans in foods and beverages. The most abundant lignan sources are flaxseed and sesame seeds. In the Zutphen Elderly Study most of the lignans came from tea, vegetables, bread, coffee, fruit and wine.
A Mediterranean style diet was consistently associated with lower cardiovascular risk
Adhering to a Mediterranean style diet was associated with a 39% lower coronary mortality risk and a 29% lower cardiovascular mortality risk in middle-aged and elderly European men and women in the HALE project. The Mediterranean diet score we used was based on eight basic food groups: bread, legumes, vegetables, fruit, fish, fats, dairy products and meats. A high intake of bread, legumes, vegetables, fruit and fats rich in unsaturated fatty acids, a moderate intake of fish and a low intake of dairy and meat was characteristic of a Mediterranean diet.
Measuring habitual diets
The HALE project dealt with European elderly men and women participating in the FINE and the SENECA Studies. They were 70-90 years old at baseline and were followed for 10 years. In both studies the dietary history was recorded as the measure of habitual food consumption.
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