Impact of major cardiovascular disease risk factors, particularly in combination, on 22-year mortality in women and men.

BACKGROUND: The appropriateness of current cardiovascular disease (CVD) risk factor guidelines in women continues to be debated. OBJECTIVE: To present new data on the appropriateness of current CVD risk factor guidelines, for women and men, from long-term follow-up of a large population sample. METHODS: Cardiovascular disease risk factor status according to current clinical guidelines and long-term impact on mortality were determined in 8686 women and 10503 men aged 40 to 64 years at baseline from the Chicago Heart Association Detection Project in Industry; average follow-up was 22 years. RESULTS: At baseline, only 6.6% of women and 4.8% of men had desirable levels for all 3 major risk factors (cholesterol level, <5.20 mmol/L [<200 mg/dL]; systolic and diastolic blood pressure, <120 and <80 mm Hg, respectively; and nonsmoking). With control for age, race, and other risk factors, each major risk factor considered separately was associated with increased risk of death for women and men. In analyses of combinations of major risk factors, risk increased with number of risk factors. Relative risks (RRs) associated with any 2 or all 3 risk factors were similar: for coronary heart disease mortality in women, RR= 5.72 (95% confidence interval [CI], 2.35-13.93), and in men, RR = 5.51 (95% CI, 3.10-9.77); for CVD mortality in women, RR = 4.54 (95% CI, 2.33-8.84), and in men, RR = 4.12 (95% CI, 2.56-6.37); and for all-cause mortality in women, RR = 2.34 (95% CI, 1.73-3.15), and in men, RR = 3.20 (95% CI, 2.47-4.14). Absolute excess risks were high in women and men with any 2 or all 3 major risk factors. CONCLUSIONS: Combinations of major CVD risk factors place women and men at high relative, absolute, and absolute excess risk of coronary heart disease, CVD, and all-cause mortality. These findings support the value of (1) measurement of major CVD risk factors, especially in combination, for assessing long-term mortality risk and (2) current advice to match treatment intensity to the level of CVD risk in both women and men.

Relationship between changes in dietary sucrose and high density lipoprotein cholesterol: the CARDIA study. Coronary Artery Risk Development in Young Adults.

PURPOSE: Cross-sectional data from several observational studies have suggested that dietary sucrose may be inversely associated with high density lipoprotein cholesterol (HDL-C). This study examined associations between energy from dietary sucrose and HDL-C at baseline, year 7 and longitudinally (year 7 minus baseline) in a cohort of young black and white men and women from the Coronary Artery Risk Development in Young Adults (CARDIA) study. METHODS: The sample included 4734 black men, black women, white men and white women, ages 18-30 years, in 1985-86 (baseline); 3513 at year 7; and 3335 for longitudinal analyses. Multivariate analyses was used with adjustment for age, BMI, cigarettes smoked per day, physical activity score, and alcohol intake. RESULTS: Multivariate analyses indicated that energy intake from sucrose was inversely associated with HDL-C for each race-gender group at baseline, year 7, and longitudinally from baseline to year 7. This association was significant at baseline for black men, and white men and women (p < 0.01); at year 7 for white men and black women (p < 0.01), and longitudinally for white men, white women, and black women (p < 0.05). CONCLUSIONS: The consistent inverse associations between energy from dietary sucrose and HDL-C observed in both cross-sectional and longitudinal analyses, and in different race and gender groups in CARDIA suggest that lowering dietary sucrose intake may be beneficial for those who may have low HDL-C.

Factor VII, cholesterol, and triglycerides. The CARDIA Study. Coronary Artery Risk Development in Young Adults Study.

Cross-sectional studies have shown that factor VII coagulant activity (VIIc) is positively associated with plasma total cholesterol (TC), LDL cholesterol, and triglycerides (TG) as well as body mass index (BMI) and diastolic blood pressure. To determine whether changes in VIIc parallel changes in coronary risk factors over a period of 2 years, we examined data from 1514 participants in the Coronary Artery Risk Development in Young Adults Study (CARDIA), an ongoing investigation of lifestyles and evolution of cardiovascular risk factors. Subjects were 23 to 35 years old at the year 5 examination. Cross-sectional analyses at these examinations showed that VIIc was positively correlated (P < .001) with TC and TG in all race/sex groups except for TC in black women at the year 5 examination. Changes in VIIc over the 2-year period were correlated positively with changes in TC in all except black men and TG in all groups; the association of VIIc change with change in TC and TG was reduced only slightly with adjustment for age and BMI at year 5 and 2-year change in BMI. To determine whether the higher levels of VIIc in subjects with higher lipid values were due to activation of the factor or to an increase in the concentration of the factor VII clotting protein, we measured factor VII antigen (VIIag) in a randomly selected subsample of 223 subjects at the year 7 examination. In all sex/race groups, VIIag correlated with VIIc (r = .69 to 0.81). After adjustment for sex and race, the partial correlation coefficient between TG and VIIc was .28 (P = .0001); between TG and VIIag, .35 (P = .0001); between TC and VIIc, .39 (P = .0001); and between TC and VIIag, 0.43 (P = .0001). No associations were observed between lipid levels and the ratio of VIIc to VIIag. We conclude that the raised VIIc with higher lipid levels occurs in blacks as well as whites, in men and women, persists over time, and represents a true increase in the plasma concentration of this clotting factor.

Prevalence and identification of abnormal lipoprotein levels in a biracial population aged 23 to 35 years (the CARDIA Study). The Coronary Artery Risk Development in Young Adults Study.

This study examines the prevalence of abnormal low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol levels in young adults to determine the ability of National Cholesterol Education Program Adult Treatment Panel (ATP) guidelines to identify persons with elevated LDL cholesterol, to compare other algorithms with those of the ATP, and to determine the contributions of race, gender, and other coronary artery disease risk factors to identifying patients with elevated LDL and low HDL cholesterol. The cohort was population-based, aged 23 to 35 years, and included relatively equal numbers of blacks and whites, and men and women. The prevalence of LDL cholesterol > or = 160 mg/dl (> 4.1 mmol/L) was 5% in black women, 4% in white women, 10% in black men, and 9% in white men. ATP identified most participants with elevated LDL cholesterol (range: 58.8% of white men to 70.7% of black women). Lipoprotein panels would have been required in 6% to 7% of women and to 15% to 18% of men. Algorithms that used nonlipid risk factors required more lipoprotein panels and identified fewer additional participants at risk. The prevalence of HDL cholesterol < 35 mg/dl (0.9 mmol/L) was 3% in women, 7% in black men, and 13% in white men. Algorithms that used nonlipid risk factors before measuring HDL cholesterol would require HDL cholesterol measurements in 35% of whites and 56% of blacks, but reduced sensitivity for identifying low HDL cholesterol (range: 58% in white men to 93% in black women). In young adults, algorithms based on nonlipid risk factors and family history have lower sensitivity, and increase rather than decrease the number of fasting lipoprotein panels required when compared with ATP levels.

Blood pressure in young blacks and whites: relevance of obesity and lifestyle factors in determining differences. The CARDIA Study. Coronary Artery Risk Development in Young Adults.

BACKGROUND: Middle-aged black men and women have higher blood pressure, on average, than whites. However, this pattern is inconsistent in children and adolescents. This study explores how differences in lifestyle factors in young adulthood may influence blood pressure patterns in the two races. METHODS AND RESULTS: The Coronary Artery Risk Development in Young Adults (CARDIA) study is an ongoing collaborative investigation of lifestyle and the evolution of cardiovascular disease risk factors in a random sample of young adults ages 18 to 30 years at baseline (1985 to 1986). Data from four examinations over 7 years were analyzed with the use of a method that simultaneously examined cross-sectional and longitudinal relationships of lifestyle factors and blood pressure. This study included 1154 black women, 853 black men, 1126 white women, and 1013 white men. Blacks had higher systolic blood pressure and diastolic blood pressure than whites at every examination. Racial differences were much greater in women than in men and increased over time. Within each sex-race group, average diastolic blood pressure over four examinations was positively associated with baseline age, body mass index, and alcohol intake and negatively associated with physical activity, cigarette use, and intake of potassium and protein. Longitudinal change in diastolic blood pressure was positively associated with changes in body mass index and alcohol intake. After adjustment for obesity and other lifestyle factors, black-white diastolic blood pressure differences were reduced substantially: 21% to 75% for men and 49% to 129% for women. Results for systolic blood pressure were similar. CONCLUSIONS: Differences in obesity and other lifestyle factors in young adults largely explain the higher baseline blood pressure and greater increase over time of blacks relative to whites.

Relationship among Lewis phenotype, clotting factors, and other cardiovascular risk factors in young adults.

An increased risk of ischemic heart disease has been reported in men with the Lewis blood group phenotype Le(a-b-). We have investigated the relationship between Lewis phenotype and cardiovascular risk factors in 1714 participants in the Coronary Artery Risk Development in Young Adults Study, an ongoing investigation on life-styles and evolution of cardiovascular risk factors. No significant differences were observed among Lewis phenotypes for body mass index, blood lipid levels, blood pressure, or clotting factors VII and fibrinogen. However, in white men with blood groups A, B, or AB, and the Le(a-b-) phenotype, significantly higher levels of factor VIII (p < 0.01) and von Willebrand factor (p < 0.03) were observed than in those with other Lewis phenotypes (Le[a+b-] or Le[a-b+]). Two-way analysis of variance indicated a significant interaction between blood group and Lewis phenotype (p = 0.0053) in terms of relationship to factor VIII. A similar trend was observed in black men with blood type A, B, or AB, and phenotype Le(a-b-) for factor VII/von Willebrand factor and in women with blood type A, B, or AB, and phenotype Le(a-b-) for factor VIII. Our data suggest that the Le(a-b-) phenotype and blood groups A, B, and AB, by virtue of their association with raised levels of factor VIII and von Willebrand factor, may be risk markers for future atherothrombotic disease.

Hemostatic factors in the Coronary Artery Risk Development in Young Adults (CARDIA) Study.

Elevated levels of factor VII (FVII) and fibrinogen (Fb) have been reported as risk factors for coronary heart disease in middle-aged and older adults. The purpose of this study was to determine whether increased levels of these and other hemostatic factors (FVIII, von Willebrand factor [vWF]) were associated with other coronary risk factors in young adults participating in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Hemostatic factors were measured in 1724 participants aged 23 to 35 years who were roughly balanced by sex and race (black/white). Fb was greater in women than men (black, 288 versus 253 mg/dL; white, 267 versus 240 mg/dL; overall P < .05 by Scheffé multiple-comparison test), and FVIII and vWF were higher in blacks than in whites (FVIII in men, 103% versus 88%, and in women, 104% versus 91%; vWF in men, 114% versus 98%, and in women, 117% versus 99%; P < .05). The latter factors were lower in those with blood group O, but within each blood group (except group A), blacks had significantly higher levels of FVIII and vWF. Fb was positively correlated with body mass index (r = .27 to .48, P < .001), total cholesterol (r = .13 to .17, P < .05), and low-density lipoprotein cholesterol (r = .15 to .22, P < .01) in all groups and with blood pressure, triglycerides, and cigarette smoking in white men. FVII correlated positively with cholesterol (r = .12 to .29, P < .05) and triglycerides (r = .23 to .32, P < .001) in all groups and with low-density lipoprotein in whites.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship of postload plasma glucose to mortality with 19-yr follow-up. Comparison of one versus two plasma glucose measurements in the Chicago Peoples Gas Company Study.

OBJECTIVE: To explore the relationship of one versus two postload plasma glucose measurements to 19-yr mortality in men in the Chicago Peoples Gas Company Study. RESEARCH DESIGN AND METHODS: One-hour postload plasma glucose was measured twice (1.4 yr apart, 1965-1967) for 873 nondiabetic men 34-65 yr of age. Serum cholesterol, blood pressure, height, and weight were measured. Data on smoking habits were obtained. Mortality follow-up was complete through July 1986, 19 yr after second glucose load. RESULTS: In prospective analyses, with each of three glucose values--first, second, and mean of first and second--coronary, cardiovascular, and all-cause age-adjusted mortality rates were higher in quintiles 3, 4, and 5 compared with quintile 1, with a significant linear trend. Multivariate analyses with glycemia as a continuous variable confirmed a positive independent association between plasma glucose and mortality endpoints with first measurement and mean of two values but not with second. With dichotomization of plasma glucose (greater than or equal to 11.2 mM [greater than or equal to 200 mg/dl]) for 30 men hyperglycemic both times, CHD and CVD death rates were significantly higher (odds ratios 2.3-2.7) compared with those for 758 men consistently nonhyperglycemic. In contrast, for those hyperglycemic once only, death rates were not significantly higher. Results of multivariate analyses were consistent with these findings. CONCLUSIONS: These data indicate a significant relationship of asymptomatic hyperglycemia on repeat examinations to coronary and cardiovascular mortality independent of other factors measured in the study.

Random digit dialing in Chicago CARDIA: comparison of individuals with unlisted and listed telephone numbers.

Young adult blacks and whites aged 18-30 years of both low and high educational levels were recruited through random digit dialing to participate in the Chicago, Illinois, portion of a longitudinal study, Coronary Artery Risk Development in Young Adults (CARDIA). Overall, 31% of randomly selected persons eligible to participate had unlisted telephone numbers--about 50% of black men and women and 11% and 17% of white men and women, respectively. There was no difference in proportions of numbers unlisted by educational level, except for white men, who were more likely to have unlisted numbers at a low educational level than at a high educational level. There was no consistent pattern of differences in rates of participation across race, sex, or education subgroups for unlisted and listed numbers, and there were no significant differences for selected health measures, except smoking. The findings suggest that in Chicago, there is a potential bias in estimates of sociodemographic characteristics from the exclusion of unlisted numbers, but it is likely to be insignificant if recruitment is stratified according to race, sex, and education. Within strata, there was little bias with respect to the attributes measured. Ideally, to guard against possible bias, random digit dialing is recommended as the preferred way to select a representative population-based sample.

Evaluation of two biological markers of tobacco exposure. MRFIT Research Group.

This study assesses serum thiocyanate and expired-air carbon monoxide based on findings for 8,895 participants in the Multiple Risk Factor Intervention Trial. For each marker and combination of markers, a logistic probability model was used to generate a plot of true positive vs false positive rates (an operating characteristic curve), an optimal cutpoint, and the positive predictive value for discriminating tobacco smokers (cigarettes, pipes, cigars, or cigarillos) from non-tobacco smokers. Optimal cutpoints were 83 mumols/liter for thiocyanate and 10 ppm for carbon monoxide. These cutpoints were applied to the entire group to evaluate accuracy. Specificity was higher for carbon monoxide than for thiocyanate (91.8 vs 87.3%) and sensitivity was lower (85.7% for carbon monoxide vs 88.8% for thiocyanate). When carbon monoxide and thiocyanate were both used, specificity was 92.7% and sensitivity was 89.1%. The estimated cutpoints derived from the Multiple Risk Factor Intervention Trial result in predictive values greater than 87% when the prevalence of smokers is greater than 50%. Cutpoints should be modified to maximize the predictive value when the prevalence of smokers is less than 50%. Both serum thiocyanate and carbon monoxide are good markers of smoking exposure. Serum thiocyanate may be preferable to carbon monoxide because of its longer half-life.