International Task Force for Prevention of Coronary Heart Disease

International Task Force for Prevention of
Coronary Heart Disease

CORONARY HEART DISEASE: REDUCING THE RISK

Bernhardt R, Feng Z, Siegrist J, Cremer P, Deng Y, Dai G, Schettler G (1990) Die Wuhan Studie. Springer Verlag, Berlin Heidelberg, 1-92

Corti MC, Guralnik JM, Salive ME, Harris T, Ferrucci L, Glynn RJ, Havlik RJ (1997) Clarifying the direct relation between total cholesterol levels and death from coronary heart disease in older persons. Ann Intern Med 126: 753-760

Cullen P, Schulte H, Assmann G (1997) The Münster Heart Study (PROCAM). Total mortality in middle-aged men is increased at low total and LDL concentrations in smokers but not in non smokers. Circulation 96: 2128-2136

Comment: In the PROCAM study, one of the largest prospective epidemiological studies in Europe, increased mortality at low cholesterol concentrations was confined to smokers and explained completely by an increase in smoking-related cancer deaths. This provides further evidence that low cholesterol per se is not a cause of increased mortality

Ebrahin S, Smith GD (1997) Systematic review of randomised controlled trials of multiple risk factor interventions for preventing coronary heart disease. Br Med J 314: 1666-1674

Comment: The pooled effect of multiple risk factor intervention on mortality were insignificant and a small, but potentially important benefit of treatment (about 10% reduction in mortality) may have been missed. Changes in risk factors were modest and in some cases may have been overestimated because of regression to the mean, lack of intention to treat analysis, habituation to blood pressure measurement and use of self reports smoking. Intervention using personal or family counselling and education seem to be more effective at reducing risk factors and therefore mortality in high risk hypertensive populations. The evidence suggests that such interventions have limited use in the general population. Health protection through fiscal and legislative measures may be more effective

Hara H, Egusa G, Yamakido M, Kawate R (1994) The high prevalence of diabetes mellitus and hyperinsulinemia among the Japanese-Americans living in Hawaii and Los Angeles. Diab Res Clin Practice 24: S37-S42

Comment: On oral glucose tolerance testing, a higher prevalence of glucose intolerance was found among persons of Japanese Ancestry living in Hawaii and Los Angeles than among residents of Hiroshima in Japan. It is especially noteworthy that the plasma insulin level markedly increased as body mass index increased in Japanese in America, while among the Japanese in Japan the increase of insulin with increasing body weight was minimal. A significant difference in food composition was present between both groups. While the Japanese in Japan consumed a diet rich in crude carbohydrate (rice), but low in refined carbohydrate (sugar), those in America consumed a diet rich in refined carbohydrate but low in crude carbohydrate. Even today, marked differences in mortality from myocardial infarction and ischemic heart disease exist between Japan and the US. This study showed a markedly higher incidence of ischaemic heart disease among Japanese living in the US compared to those living in Japan

Janus ED, Postiglione A, Singh RB, Lewis B (1996) The modernisation of Asia. Implications for coronary heart disease. Circulation 94: 2671-2673

Comment: Changes in health-related behaviour (diet, smoking, sedentary life style) may underlie the pronounced increase in CHD mortality in countries with formerly low rates of the disease. This editorial addresses the implications for prevention policy in industrialising, developing countries. Regional differences in emphasis are likely to be needed, but common principles govern preventive measures

Kagan A, Harris BR, Winkelstein W, Johnson KG, Katao H, Syme SL, Roads GG, Gay ML et al (1974) Epidemiological studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: demographic, physical, dietary and biochemical characteristics. J Chron Dis 27:345-364

Comment: The now classical Ni-Hon-San (Nippon-Honolulu-San Francisco) study was carried out between 1966 and 1970. Its specific goal was a precise estimate of the prevalence, incidence, and mortality of coronary heart disease and cerebrovascular disease among Japanese men in the three areas, a precise delineation of differences in the prevalence of established risk factors, and a determination of the relations between risk factors and between risk factors and disease. California and Honolulu men were, on average, 8 kg heavier than their Japanese counterparts. Both American cohorts showed markedly higher serum cholesterol values than those in Japan (J:176, H:219, C:228 at ages 50-54 years). Blood pressure was distinctly higher in the California cohort. Serum glucose values determined 1 hour after an oral glucose load in Hawaii exceeded those in Japan at all ages. The mean value for total calories was only slightly lower in Japan than in Hawaii and California, but the fat intake in Japan was markedly lower than in America (15% vs 33% and 38% respectively)

Law MP, Wald N, Thompson SG (1994) By how much and how quickly does reduction in serum cholesterol lower risk of ischaemic heart disease? Br Med J 130: 367-373

Comment: A definitive meta-analysis of pre-statin cholesterol lowering trials, showing a significant and substantial reduction in coronary events proportionate to the absolute reduction in serum-and LDL-cholesterol, by diet and by drug treatment, and in primary and secondary prevention. Most of the difference in risk predicted from epidemiological studies is achieved by cholesterol lowering within a period of 5 years

Law MR, Wald NJ, Eackshaw A, Bailey A (1994) Systematic underestimation of association between serum cholesterol and ischemic heart disease in observational studies: data from the BUPA Study. Br Med J 308: 363-366

Comment: The association between serum cholesterol concentration

and death from ischemic heart disease is stronger than directly inferred from prospective epidemiological studies because of two sources of underestimation that affect these studies. Correction for the underestimation makes the association about half as strong again: a 30% reduction in ischemic heart disease at age 60, instead of 20%, for a 10% reduction in serum cholesterol concentration. The effect of underestimation was quantified in this study and used to correct the results of other prospective studies. No excess mortality from any cause was apparent in men with low cholesterol concentration

Lewis B, Tikkanen MJ (1994) Low blood total cholesterol and mortality. Causality, consequence, and confounders. Am J Cardiol 73: 80-85

Comment: There had been considerable concern that low serum cholesterol levels, and cholesterol-lowering treatments, might increase the risk of such noncardiovascular causes of death as cancer, depression, suicide and accident proneness. This analysis of the epidemiology, of cholesterol-lowering trials, and of cellular mechanisms, concludes that there is little basis for such concerns. Where low cholesterol is associated with non-cardiovascular mortality, the low cholesterol level is the consequence, not the cause, or confounding explains the association. Cells meet their cholesterol requirements largely or entirely by synthesis of cholesterol in situ

People’s Republic of China-United States Cardiovascular and Cardiopulmonary Epidemiology Research Group (1992) Baseline report from the PRC-USA collaborative study: An epidemiological study of cardiovascular and cardiopulmonary disease risk factors in four populations in the People’s Republic of China. Circulation 85: 1083-1096

Comment: The baseline data collected in four PRC samples for age 35-54 years in the early 1980s (northern urban, northern rural, southern urban, and southern rural) show contrasting findings both among the PRC samples and the US samples for blood pressure, serum lipids, BMI, and smoking. Based on these findings, multiple issues relating to the aetiology of major adult cardiovascular and cardiopulmonary diseases can be fruitfully explored, particularly as incidence data are collected by periodic resurvey of the cohorts

Smith GD, Song F, Seeldon TA (1993) Cholesterol lowering and mortality: the importance of considering initial level of risk. Br Med J 306: 1367 -1373

Comment: Currently evaluated cholesterol lowering drugs seem to produce mortality benefits in only a small proportion of patients at a very high risk of death from CHD. Population cholesterol screening could waste resources and even result in net harm in substantial groups of patients. Cholesterol levels should not remain the principal focus of clinical guidelines for the prevention of CHD. Global risk assessment should instead be the main focus of such a guideline and a cautious approach to use cholesterol lowering drugs should be advocated. Future trials should aim to clarify the level of risk above which treatment is of net benefit

Stehle G, Bernhardt R (1987) Coronary risk factors in Japan and China. Springer Verlag, Berlin, Heidelberg, 1-53

Comment: This booklet presents a survey on CHD among the Japanese and Chinese populations with special regard to nutritional and occupational factors. Blood lipid patterns as seen in the examination of 13,630 healthy Japanese men and women are reported. Changing nutritional habits resulting in increased total cholesterol and triglyceride levels are discussed. A comparison of CHD risk factors between Chinese and German middle-aged workers is also reported

Sytkowski PA, D’Agostino RB, Belanger A, Kannel WB (1996) Sex and time trends in cardiovascular disease incidence and mortality: The Framingham Heart Study, 1950-1989. Am J Epidemiol 143: 338-350

Comments: The authors examined 20-year trends in risk factors, incidence and mortality among women and men in Framingham, who were members of the Framingham Heart Study and aged 50-59 years in 1950, 1960, and 1970. Cardiovascular disease mortality declined 59% between the female cohorts and 53% between the male cohorts (both p<0.001 for trend). More than half of the 51% decline in coronary heart disease mortality observed in women and one third to one half of the 44% decline observed in men could be attributed to the improvement in risk factors profile

The World Health Report 1997: conquering suffering, enriching humanity. World Health Organization, Geneva 1997, p. 39.

Thompson GR (1997)What targets should lipid-modulating therapy achieve to optimise the prevention of coronary heart disease? Atherosclerosis 131, 1-5

Comment: Analysis of trials which have investigated the effects of lowering LDL-cholesterol levels on CHD, as determined by changes or quantitative coronary angiography and in the incidence of cardiovascular events, suggests that the percentage decrease in LDL-cholesterol provides a better index of outcome than does it absolute level on treatment. Additional data suggest that it may be advantageous to employ therapy which not only lowers LDL-cholesterol but also decreases serum triglyceride and/or increases HDL-cholesterol. These conclusions have important implications for future guidelines on CHD prevention

Tunstall-Pedoe H et al for the WHO MONICA project. Myocardial infarction and coronary deaths in the WHO MONICA project 1985-90: how trends in male and female incidence, population case fatality and mortality relate across 40 populations. Circulation (in press)

Tunstall-Pedoe H, Kuulasmaa K, Amouyel P, Arveiller D, Rajakangas AM, Pajak A for the WHO MONICA project (1994) Myocardial infarction and coronary deaths in the World Health Organization MONICA Project. Registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. Circulation 90: 583-612

Ueshima H for the Research Committee of the National Integrated Project for Prospective Observation of Non-Communicable Disease and its Trends in the Aged (1997) Results of the prospective observation on the subjects of National Surveys of Circulatory Disorders 1980. J. Japanese Association for Cerebro-cardiovascular Disease Control 31: 231-237 (in Japanese)

Comment: Fourteen years follow-up of 4,295 men and 5,473 women randomly selected from various districts of Japan at the time of the National Surveys of Circulatory Disorders 1980 showed that the mortality from both stroke and ischemic heart disease were markedly higher among the people with higher blood pressure. Smoking also strongly influenced mortality from stroke. Higher cholesterol levels, especially values exceeding 260 mg/dL were associated with increased mortality from ischaemic heart disease

WHO Expert Committee. Physical Status: the use and interpretation of anthropometry. WHO Technical Report Series no. 854. Geneva, WHO, 1995