Framingham Heart Study, Cardiovascular Health Study (CHS), Coronary Artery
Risk Development in Young Adults (CARDIA), and Other Population Based Research
Abstract: We estimated the coronary heart disease (CHD) events that
are preventable by treatment of lipids and blood pressure in patients with
metabolic syndrome (MetS), a contributor to coronary heart disease (CHD). Among
patients aged 30 to 74 years (without diabetes or CHD) in the United States,
MetS was defined by National Cholesterol Education Program criteria. CHD events
over a period of 10 years were estimated by Framingham algorithms. Events that
could be prevented by statistically "controlling" blood pressure, low-density
lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol
to either normal or optimal levels according to national guidelines were
calculated. Of 7.5 million men and 9.0 million women aged 30 to 74 years with
MetS, approximately 1.5 million men and 0.45 million women, if untreated,
developed CHD events in 10 years. In men and women, blood pressure control to
normal levels "prevented" 28.1% and 12.5% of CHD events, respectively (p <0.01);
control to optimal levels resulted in preventing 28.2% and 45.2% of events,
respectively (p <0.01). Control of HDL cholesterol to normal levels resulted
in preventing 25.3% of events in men and 27.3% in women; optimal control
prevented 51.2% and 50.6% of events, respectively. Control of LDL cholesterol
to normal levels prevented 9.3% of events in men and 9.8% of events in women;
control to optimal levels prevented 46.2% and 38.1% of events (p <0.05),
respectively. Control of all 3 risk factors to normal levels resulted in
preventing 51.3% of events for men and 42.6% for women; control to optimal
levels resulted in preventing 80.5% and 82.1% of events, respectively. Thus,
many CHD events in patients with MetS may be preventable by nominal or
optimal control of lipids and/or blood pressure.
- Wong ND, Pio JR, Franklin SS, L'Italien GJ, Kamath TV, Williams GR.
; Larson MG; Levy D.
- Preventing coronary events by optimal control of blood pressure and lipids in
patients with the metabolic syndrome.
- Am J Cardiol. 2003 Jun 15;91(12):1421-6.
Unique ID: 12804727.
BACKGROUND: Hypertension is related to significant morbidity and
mortality rates from coronary heart disease (CHD). This report examines
the relative and absolute impact on risk for CHD by controlling
hypertension to high normal and optimal levels. METHODS: Among all
subjects with untreated or inadequately treated hypertension in the
National Health and Nutrition Examination Survey (NHANES) III who were
30 to 74 years of age and without prior CHD, the 10-year risk of CHD
was calculated. With the use of sampling weights, the number of CHD
events by age group, hypertension subtype (isolated diastolic
hypertension [IDH], systolic-diastolic hypertension [SDH], and isolated
systolic hypertension [ISH]), and stage of hypertension was estimated.
Risk was recalculated and the number of events reestimated, assuming a
reduction in blood pressure (BP) to high normal and optimal levels. The
number and proportion (population-attributable risk, or PAR%) of events
that could be prevented were determined from the differences in events
and risk between uncontrolled and controlled BP levels. Derived from
this was the number of persons needing treatment per CHD event
prevented. RESULTS: Control of hypertension to high normal levels could
prevent approximately one fifth (PAR 19%) of CHD events in men and one
third (PAR = 31%) of CHD events in women, whereas control to optimal
levels may prevent 37% and 56% of CHD events, respectively (P <.01
for differences between men and women). Of CHD events that could be
prevented, the greatest proportion occurred from controlling BP among
older persons, men, and those with stage 1 hypertension (vs stages 2
and 3) or with ISH (vs IDH or SDH). The number of persons with
hypertension needing treatment to prevent one CHD event ranged from
20.5 in men to 38.6 in women when controlled to high normal BP and 10.7
in men and 21.3 in women when controlled to optimal BP. CONCLUSIONS:
The greatest impact from control of hypertension occurs in older
persons, men, and those with ISH, whereas the greatest PAR% occurred in
women. Optimal control of BP could prevent more than one third of CHD
events in men and more than half of events in women. Greater efforts to
control hypertension in these populations may have a substantial impact
in preventing CHD events.
- Wong ND, Thakral G, Franklin SS, L'Italien GJ, Jacobs MJ, Whyte JL, Lapuerta P.
- Preventing heart disease by controlling hypertension: impact of hypertensive subtype, stage, age, and sex.
- Am Heart J. 2003 May;145(5):888-95.
Unique ID: 12766749.
The authors examined the distribution of, and risk factors associated
with, the inflammatory marker C-reactive protein (CRP) among a large
sample of non-institutionalized American adults aged 30-74 years of
age, and its relation to estimated 10-year coronary heart disease risk.
The population studied comprised 4472 men and 5212 women aged 30-74
years, without coronary heart disease, who had CRP measurements in the
Third National Health and Nutrition Examination Survey (NHANES III).
The 10-year risk of coronary heart disease was estimated from
Framingham risk factor algorithms among those with CRP levels of
less-than-or-equal0.21 mg/dL, >0.21 to <0.5mg/dL, 0.5 to <1.0
mg/dL, and greater-than-or-equal1.0 mg/dL. Mean (SD) levels of CRP were
0.41 (0.64) mg/dL in men and 0.55 (0.91) mg/dL in women. Levels of at
least 1 mg/dL were measured in 6.4% of men and 12.9% of women. CRP
levels were highest among non-Hispanic black men and Mexican-American
women. According to multiple logistic regression analysis, cigarette
smoking and increased age, body mass index, and systolic blood pressure
in men, and body mass index and diabetes in women, were strongly
associated with a greater likelihood of CRP levels of
greater-than-or-equal1.0 mg/dL (p<0.001). Among persons with CRP
levels of less-than-or-equal0.21 mg/dL, >0.21 to <0.5 mg/dL, 0.5
to <1.0 mg/dL and greater-than-or-equal1.0 mg/dL, the 10-year
estimated risk of coronary heart disease were 13.4%, 17.6%, 19.6%, and
21.1% among men, respectively, and 2.7%, 3.6%, 4.1% and 4.3% among
women, respectively (both p<0.001 across CRP categories); higher
risks across CRP groups were also found among ethnic/gender subgroups.
CRP remained a significant predictor of coronary heart disease risk in
unadjusted and age-adjusted analyses. Conclusion. Elevation of CRP is
associated with several major coronary heart disease risk factors and
with unadjusted and age-adjusted projections of 10-year coronary heart
disease risk in both men and women. (c)2001 CHF, Inc. Presented at the
Fifth International Conference on Preventive Cardiology, Osaka, Japan,
- Wong ND, Pio J, Valencia R, Thakal G.
- Distribution of C-reactive protein and its relation to risk factors and
coronary heart disease risk estimation in the National Health and Nutrition
Examination Survey (NHANES) III.
- Prev Cardiol. 2001 Summer;4(3):109-114.
Unique ID: 11828186.
Abstract: The purpose of the present study was to examine patterns
of systolic and diastolic hypertension by age in the nationally representative
National Health and Nutrition Examination Survey (NHANES) III and to determine
when treatment and control efforts should be recommended. Percentage distribution
of 3 blood pressure subtypes (isolated systolic hypertension, combined
systolic/diastolic hypertension, and isolated diastolic hypertension) was
categorized for uncontrolled hypertension (untreated and inadequately treated)
in 2 age groups (ages <50 and >/=50 years). Overall, isolated systolic hypertension
was the most frequent subtype of uncontrolled hypertension (65%). Most subjects
with hypertension (74%) were >/=50 years of age, and of this untreated older group,
nearly all (94%) were accurately staged by systolic blood pressure alone, in
contrast to subjects in the untreated younger group, who were best staged by
diastolic blood pressure. Furthermore, most subjects (80%) in the older untreated
and the inadequately treated groups had isolated systolic hypertension and
required a greater reduction in systolic blood pressure than in the younger
groups (-13.3 and -16.5 mm Hg versus -6.8 and -6.1 mm Hg, respectively; P:=0.0001)
to attain a systolic blood pressure treatment goal of <140 mm Hg. Contrary to
previous perceptions, isolated systolic hypertension was the majority subtype of
uncontrolled hypertension in subjects of ages 50 to 59 years, comprised 87%
frequency for subjects in the sixth decade of life, and required greater reduction
in systolic blood pressure in these subjects to reach treatment goal compared with
subjects in the younger group. Better awareness of this middle-aged and older
high-risk group and more aggressive antihypertensive therapy are necessary to
address this treatment gap.
- Franklin SS, Jacobs MJ, Wong ND, L'Italien GJ, Lapuerta P.
- Predominance of isolated systolic hypertension among middle-aged and elderly
US hypertensives: analysis based on National Health and Nutrition Examination
Survey (NHANES) III.
- Hypertension. 2001 Mar;37(3):869-74.
Unique ID: 11244010.
Abstract:BACKGROUND: We examined the relative importance of diastolic
(DBP), systolic (SBP) and pulse pressure (PP) as predictors of coronary heart
disease (CHD) risk in different age groups of Framingham Heart Study participants.
METHODS AND RESULTS: We studied 3060 men and 3479 women between 20 and 79 years
of age who were free of CHD and were not on antihypertensive drug therapy at
baseline. Cox regression adjusted for age, sex, and other risk factors was used
to assess the relations of BP indexes to CHD risk over a 20-year follow-up. In
the group <50 years of age, DBP was the strongest predictor of CHD risk (hazard
ratio [HR] per 10 mm Hg increment, 1.34; 95% CI, 1.18 to 1.51) rather than SBP
(HR, 1.14; 95% CI, 1.06 to 1.24) or PP (HR, 1.02; 95% CI, 0.89 to 1.17). In the
group 50 to 59 years of age, risks were comparable for all 3 BP indexes. In the
older age group, the strongest predictor of CHD risk was PP (HR, 1.24; 95% CI,
1.16 to 1.33). When both SBP and DBP were considered jointly, the former was
directly and the latter was inversely related to CHD risk in the oldest age group
CONCLUSIONS: With increasing age, there was a gradual shift from DBP to SBP and
then to PP as predictors of CHD risk. In patients <50 years of age, DBP was the
strongest predictor. Age 50 to 59 years was a transition period when all 3 BP
indexes were comparable predictors, and from 60 years of age on, DBP was negatively
related to CHD risk so that PP became superior to SBP.
- Franklin SS, Larson MG, Khan SA, Wong ND, Leip EP, Kannel WB, Levy D.
- Does the relation of blood pressure to coronary heart disease risk
change with aging? The Framingham Heart Study.
- Circulation. 2001 Mar 6;103(9):1188-90. Circulation. 2001 Nov 27;104(22):E128-9.
Unique ID: 11238268.
Abstract: BACKGROUND: Current definitions of hypertension are based on levels
of systolic blood pressure (SBP) and diastolic blood pressure (DBP), but
not on pulse pressure (PP). We examined whether PP adds useful information
for predicting coronary heart disease (CHD) in the population-based
Framingham Heart Study. METHODS AND RESULTS: We studied 1924 men and women
between 50 and 79 years of age at baseline with no clinical evidence of CHD
and not taking antihypertensive drug therapy. Cox regression, adjusted for
age, sex, and other risk factors, was used to assess the relations between
blood pressure components and CHD risk over a 20-year follow-up. The
association with CHD risk was positive for SBP, DBP, and PP, considering
each pressure individually; of the 3, PP yielded the largest chi(2)
statistic. When SBP and DBP were jointly entered into the multivariable
model, the association with CHD risk was positive for SBP (HR, 1.22; 95%
CI, 1.15 to 1.30) and negative for DBP (HR, 0. 86; 95% CI, 0.75 to 0.98).
Four subgroups were defined according to SBP levels (<120, 120 to 139, 140
to 159, and >/=160 mm Hg). Within each subgroup, the association with CHD
risk was negative for DBP and positive for PP. A cross-classification of
SBP-DBP levels confirmed these results. CONCLUSIONS: In the middle-aged and
elderly, CHD risk increased with lower DBP at any level of SBP>/=120 mm Hg,
suggesting that higher PP was an important component of risk. Neither SBP
nor DBP was superior to PP in predicting CHD risk.
- Franklin SS; Khan SA; Wong ND; Larson MG; Levy D.
- Is pulse pressure useful in predicting risk for coronary heart
Disease? The Framingham heart study.
- Circulation, 1999 Jul 27, 100(4):354-60.
Unique ID: 99350763.
BACKGROUND: We attempted to characterize age-related changes in blood pressure
in both normotensive and untreated hypertensive subjects in a population-based
cohort from the original Framingham Heart Study and to infer underlying
hemodynamic mechanisms. METHODS AND RESULTS: A total of 2036 participants were
divided into four groups according to their systolic blood pressure (SBP) at
biennial examination 10, 11, or 12. After excluding subjects receiving
antihypertensive drug therapy, up to 30 years of data on normotensive and
untreated hypertensive subjects from biennial examinations 2 through 16 were
used. Regressions of blood pressure versus age within individual subjects
produced slope and curvature estimates that were compared with the use of ANOVA
among the four SBP groups. There was a linear rise in SBP from age 30 through 84
years and concurrent increases in diastolic blood pressure (DBP) and mean
arterial pressure (MAP); after age 50 to 60 years, DBP declined, pulse pressure
(PP) rose steeply, and MAP reached an asymptote. Neither the fall in DBP nor the
rise in PP was influenced significantly by removal of subsequent deaths and
subjects with nonfatal myocardial infarction or heart failure. Age-related
linear increases in SBP, PP, and MAP, as well as the early rise and late fall in
DBP, were greatest for subjects with the highest baseline SBP; this represents a
divergent rather than parallel tracking pattern. CONCLUSIONS: The late fall in
DBP after age 60 years, associated with a continual rise in SBP, cannot be
explained by "burned out" diastolic hypertension or by "selective survivorship"
but is consistent with increased large artery stiffness. Higher SBP, left
untreated, may accelerate large artery stiffness and thus perpetuate a vicious
- Franklin SS; Gustin W IV; Wong ND; Larson MG; Weber MA;
Kannel WB; Levy D.
- Hemodynamic patterns of age-related changes in blood pressure. The
Framingham Heart Study.
- Circulation, 1997 Jul 1, 96(1):308-15. (UI: 97379651)
Abstract: Low left
ventricular ejection fraction (LVEF), a measure of global systolic left
ventricular dysfunction, is associated with an increased risk of recurrent
coronary events or death in persons with cardiac disease. There are few data on
the distribution of resting LVEF and component volumes in healthy young adults
or on any association of LVEF with coronary risk factors. LVEF and left
ventricular end-diastolic and end-systolic volumes (LVEDV and LVESV,
respectively) were measured by two-dimensional echocardiography in 1782 men and
women 23 to 35 years old without self-reported heart disease (other than mitral
valve prolapse, n = 53) who were participants in the multicenter Coronary Artery
Risk Development in Young Adults study. Factors analyzed as potential
contributors to LVEF, LVEDV, and LVESV included age, gender, race, blood
pressure, alcohol use, current smoking, family history of myocardial infarction,
total and high-density lipoprotein cholesterol concentrations, obesity, reported
physical activity, and fitness as assessed by treadmill exercise testing. LVEF
was lower in men (mean 62.6% SD 5.7%) than in women (mean 63.9%, SD 5.7%) (p
< 0.01) but did not differ significantly between black and white subjects.
Ninety percent of subjects had an LVEF between 53% and 71%. LVEDV and LVESV were
> 25% greater in men than in women. From multivariate analysis, male gender,
history of hypertension, and current smoking were each positively and
independently associated with an approximately 1% lower LVEF. Body surface area,
a family history of premature myocardial infarction, and treadmill workload 150
time were positively related, whereas total skinfold thickness was negatively
related to LVEDV and LVESV.(ABSTRACT TRUNCATED AT 250 WORDS)
- Wong ND; Gardin JM; Kurosaki T; Anton-Culver H; Sidney S;
Roseman J; Gidding S.
- Echocardiographic left ventricular systolic function and volumes in young
adults: distribution and factors influencing variability.
- American Heart Journal, 1995 Mar, 129(3):571-7. (UI: 95177026)
- Pub type: Journal Article; Multicenter Study.
Abstract: OBJECTIVE: To describe relationships between age
and sub-clinical cardiovascular disease, manifest chronic disease, and physical
functioning and limitations among persons aged 65 years and older, with emphasis
on the "oldest old," those 85 years and older. DESIGN: Observational
population-based study. SETTING: Four U.S. communities: Forsyth County, North
Carolina; Sacramento County, California; Washington County, Maryland; and
Pittsburgh, Pennsylvania. PARTICIPANTS: 5,201 men and women aged 65 years and
older. MEASUREMENTS: Demographic data; histories of cardiovascular disease
(CVD), chronic lung disease, arthritis, diabetes, and hypertension; measures of
subclinical disease including arm and ankle blood pressures, internal carotid
wall thickness and stenosis, ejection fraction, left ventricular mass,
fractional shortening, and diastolic function, electrocardiographic left
ventricular hypertrophy and cardiac injury score, forced expiratory flow and
volume; functional status including self-reported physical functioning, hearing
and sight limitations and health status, and performance-based measures of
function. These variables were examined among men and women in three age groups:
65-74 years, 75-84 years, and 85 + years. Subgroups of participants with and
without manifest CVD were also examined. MAIN RESULTS: In women, the prevalence
of CVD and other chronic conditions increased with age, and the highest rates
occurred among those 85 years and older. In men, prevalence rates increased
between the two younger groups, but the oldest group had lower than expected
rates for coronary heart disease, cerebrovascular disease, hypertension, and
chronic lung disease. In contrast, there were strong age-related linear trends
in most of the subclinical measures of blood pressure, atherosclerosis and
pulmonary function and in virtually all measures of functional status in both
gender groups across the age range. There was a particularly marked decline in
functional status between the two older age groups. While subclinical disease
was greater and functional status was poorer among those with manifest CVD, with
few exceptions, age-related trends were not significantly different between the
two groups. CONCLUSIONS: Lower than expected prevalence rates of CVD among those
aged 85 years and older, particularly among men, in this study of
community-dwelling elderly may represent selection bias or a real plateauing in
disease prevalence with age. However, subclinical disease appears to increase
and functional status to decline across the age range in both men and women
regardless of the presence of CVD. The apparent increase in subclinical disease
with age indicates potential for CVD prevention after age 65.
- Bild DE; Fitzpatrick A; Fried LP; Wong ND; Haan MN; Lyles M; Bovill
E; Polak JF; Schulz R.
- Age-related trends in cardiovascular morbidity and physical functioning in
the elderly: the Cardiovascular Health Study.
- Journal of the American Geriatrics Society, 1993 Oct, 41(10):1047-56.(UI:
Abstract: Preexisting cardiovascular conditions (angina pectoris,
intermittent claudication, stroke or transient ischemic attack, and congestive
heart failure) were evaluated in relation to long-term prognosis after an
initial MI in 828 subjects from the Framingham Heart Study. Preexisting angina
pectoris and intermittent claudication in men were associated with increased
risk of coronary mortality and recurrent MI, whereas congestive heart failure
increased coronary mortality. In women, prior angina pectoris increased the risk
of recurrent MI and congestive heart failure increased the coronary mortality.
Adjusting for the major cardiovascular risk factors measured before MI, these
results held for men but no significant adverse effects persisted in women.
Among subjects who survived to return for subsequent examinations, only prior
congestive heart failure in men increased the risk after adjusting for post-MI
risk factors. In women who returned, angina pectoris and intermittent
claudication were associated with poor post-MI prognosis. These results suggest
that atherosclerosis is a diffuse disease of the circulatory system, and one in
which post-MI prognosis is influenced by the presence of other preexisting
cardiovascular conditions. Hence a patient who has an MI after prior expression
of cardiovascular disease requires more vigorous preventive management.
- Cupples LA; Gagnon DR; Wong ND; Ostfeld AM; Kannel WB.
- Preexisting cardiovascular conditions and long-term prognosis after
initial myocardial infarction: the Framingham Study.
- American Heart Journal, 1993 Mar, 125(3):863-72. (UI: 93175312)
BACKGROUND. Cardiovascular disease is the leading cause of death and disability
in older people. There is little information about the distributions of risk
factors in older populations. This article describes the distribution and
correlates of lipoprotein lipids in people greater than or equal to 65 years
old. METHODS AND RESULTS. Lipoprotein lipid concentrations were measured in
2,106 men (M) and 2,732 women (F) who were participants in the Cardiovascular
Health Study, a population-based epidemiological study. Distributions of lipids
by age and sex and bivariate and multivariate relations among lipids and other
variables were determined in cross-sectional analyses. Mean concentrations of
lipids were cholesterol: M, 5.20 +/- 0.93 mmol/l (201 +/- 36 mg/dl) and F, 5.81
+/- 0.98 mmol/l (225 +/- 38 mg/dl); triglyceride (TG): M, 1.58 +/- 0.85 mmol/l
(140 +/- 75 mg/dl) and F, 1.57 +/- 0.78 mmol/l (139 +/- 69 mg/dl); high density
lipoprotein cholesterol (HDL-C): M, 1.23 +/- 0.33 mmol/l (48 +/- 16 mg/dl), and
F, 1.53 +/- 0.41 mmol/l (59 +/- 16 mg/dl); low density lipoprotein cholesterol
(LDL-C): M, 3.27 +/- 0.85 mmol/l (127 +/- 33 mg/dl) and F, 3.57 +/- 0.93 mmol/l
(138 +/- 36 mg/dl). The total cholesterol to HDL-C ratios were M, 4.49 +/- 1.29
and F, 4.05 +/- 1.22. TG, total cholesterol, and LDL-C concentrations were lower
with increasing age, the last more evident in men than in women. TG
concentration was positively associated with obesity (in women), central fat
patterning, glucose intolerance, use of beta-blockers (in men), and use of
estrogens (in women) and negatively associated with age, renal function, alcohol
use, and socioeconomic status. In general, HDL-C had opposite relations with
these variables, except that estrogen use was associated with higher HDL-C
concentrations. LDL-C concentration was associated with far fewer variables than
the other lipids but was negatively associated with age in men and women and
positively correlated with obesity and central fat patterning and negatively
correlated with renal function and estrogen use in women. There were no
differences in total cholesterol and LDL-C concentrations among participants
with and without prevalent coronary heart disease and stroke, but TG
concentration was higher and HDL-C lower in men with both coronary heart disease
and stroke and in women with coronary heart disease. CONCLUSIONS. Cholesterol
and cholesterol/HDL-C ratio were lower and HDL-C higher than previously reported
values in older people, suggesting that lipid risk profiles may be improving in
older Americans. TG and HDL-C concentrations, and to a lesser extent LDL-C, were
associated with potentially important modifiable factors such as obesity,
glucose intolerance, renal function, and medication use.
- Ettinger WH; Wahl PW; Kuller LH; Bush TL; Tracy RP; Manolio TA; Borhani
NO; Wong ND; O'Leary DH.
- Lipoprotein lipids in older people. Results from the Cardiovascular Health
Study. The CHS Collaborative Research Group [see comments].
- Circulation, 1992 Sep, 86(3):858-69. (UI: 92386686)
Abstract: Left ventricular (LV) mass, as estimated from M-mode
echocardiography (echo), has previously been shown to be an independent
predictor of incident cardiovascular disease morbidity and mortality. We
evaluated the relationship at baseline of echo LV mass to relevant
cardiovascular disease risk factors and other potential covariates in the
Cardiovascular Health Study, multicenter study sponsored by the National Heart,
Lung, and Blood Institute of 5201 men and women aged 65 years or older (mean,
73). Two-dimensionally directed M-mode echo LV mass measurements could be
obtained in 1357 men and 2053 women (66% of this elderly cohort). Stepwise
linear regression analyses of the relationship of echo LV mass to demographic
and risk factor, physical activity, electrocardiographic, and prevalent disease
variables resulted in a model that explained 37% of the variance for the entire
cohort. In order of decreasing importance, factors positively associated with
echo LV mass were body weight, male sex, systolic pressure, presence of
congestive heart failure, present smoking, major and minor electrocardiographic
abnormalities, treatment for hypertension, valvular heart disease, aortic
regurgitation by color Doppler, and mitral regurgitation by color Doppler (in
men) whereas diastolic pressure, bioresistance (a measure of adiposity), and
high-density lipoprotein cholesterol were inversely related to echo LV mass.
Although height and weight were both related to LV mass, height added nothing
once weight was entered in multiple linear regression analyses. Furthermore, in
the multiple regression models, diastolic pressure was inversely and systolic BP
positively related to LV mass, with similar magnitudes for their coefficients.
In consonance with these findings, pulse pressure was positively related to LV
mass in bivariate analyses. Multiple linear regression analyses explained less
of the variance for ventricular septal thickness (R2 = .13) and LV posterior
wall thickness (R2 = .14) than for LV mass (R2 = .37) and LV diastolic dimension
(R2 = .27). Intriguing findings in the elderly Cardiovascular Health Study
cohort included the presence of pulse pressure as a positive correlate, and
high-density lipoprotein cholesterol as an inverse correlate, of LV mass.
Longitudinal studies in the Cardiovascular Health Study cohort will help to
clarify the importance of demographic, risk factor, and other variables, and
changes in these variables, in predicting changes in echo LV mass and its
components as well as the prognostic significance of LV mass in the elderly.
- Gardin JM; Arnold A; Gottdiener JS; Wong ND; Fried LP;
Klopfenstein HS; O'Leary DH; Tracy R; Kronmal R.
- Left ventricular mass in the elderly. The Cardiovascular Health Study.
- Hypertension, 1997 May, 29(5):1095-103.
- Pub type: JOURNAL ARTICLE; MULTICENTER STUDY. (UI: 97293778)
Abstract: The Framingham study has shown by M-mode
echocardiography that left ventricular hypertrophy is a powerful, independent
predictor for the development of coronary heart disease and that increased left
atrial dimension has been associated with an increased risk of stroke. No
previous population-based study has evaluated the risk factor correlates and
predictive value for coronary heart disease and stroke of two-dimensional and
Doppler, as well as M-mode, echocardiography. The Cardiovascular Health Study is
a multi-year prospective epidemiologic study of 5201 men and women older than 65
recruited from four geographic sites in the United States. The main objectives
of incorporating echocardiography were to determine whether echocardiographic
indices, or changes in these indices, are (1) correlated with traditional risk
factors for coronary heart disease and stroke; and (2) independent predictors of
morbidity and mortality for coronary heart disease and stroke. Echocardiographic
measurements of interest include those related to global and segmental left
ventricular systolic and diastolic structure and function and left atrial size.
For each subject, a baseline echocardiogram was recorded in super-VHS tape using
a standard protocol and equipment. All studies were sent to a reading center
where images were digitized and measurements were made using customized computer
algorithms. Calculated data and images were stored on optical disks to
facilitate retrieval and future comparisons in longitudinal studies. A second
echocardiogram is scheduled in year 7, with a goal of determining whether
changes in cardiac anatomy or function over a 5-year period are important
predictors of morbidity or mortality from coronary heart disease and stroke.
Quality control measures included standardized training of echocardiography
technicians and readers, technician observation by a trained echocardiographer,
periodic blind duplicate readings with reader review sessions, phantom studies,
and quality control adults.
- Gardin JM; Wong ND; Bommer W; Klopfenstein HS; Smith VE;
Tabatznik B; Siscovick D; Lobodzinski S; Anton-Culver H; Manolio TA.
- Echocardiographic design of a multicenter investigation of free-living
elderly subjects: the Cardiovascular Health Study [published erratum appears
in J Am Soc Echocardiogr 1992 Sep-Oct;5(5):550].
- Journal of the American Society of Echocardiography, 1992 Jan-Feb,
5(1):63-72. (UI: 92153440) Pub type: Clinical Trial; Journal Article;
Abstract: OBJECTIVE: To determine the relation between serum
cholesterol levels and the long-term risk for reinfarction, death from coronary
heart disease, and all-cause mortality in persons who recover from myocardial
infarction. DESIGN: Prospective, longitudinal study. SETTING: A geographically
defined population-based cohort of adults participating in the Framingham Heart
Study. PATIENTS: Men (n = 260) and women (n = 114), 33 to 88 years of age (mean
age, 62 years), who had a history of myocardial infarction. MEASUREMENTS: A
complete physical examination, including electrocardiographic evaluation, blood
pressure measurement, height and weight measurements, determination of smoking
habits, and casual determinations of blood glucose and serum cholesterol, was
done approximately 1 year after recovery from initial myocardial infarction.
Patients were followed after infarction for the occurrence of reinfarction or
death (mean follow-up, 10.5 years; range, 0.8 to 31.6 years). MAIN RESULTS: The
mean cholesterol level after infarction was 5.21 mmol/L (242.8 mg/dL); 20% of
patients had levels below 5.17 mmol/L (200 mg/dL), and 22% had levels of 7.11
mmol/L (275 mg/dL) or more. Compared with patients who had cholesterol levels
below 5.17 mmol/L, patients with levels of 7.11 mmol/L or more were at increased
risk for reinfarction (relative risk, 3.8; 95% Cl, 1.6 to 8.7), death from
coronary heart disease (relative risk, 2.6; Cl, 1.4 to 4.8), and all-cause
mortality (relative risk, 1.9; Cl, 1.2 to 2.9) based on multivariate Cox
regression analyses adjusted for other coronary risk factors. Intermediate
cholesterol levels (5.17 mmol/L to 7.11 mmol/L) were generally not associated
with increased risk. The association between elevated serum cholesterol and
increased risk was strongest in men; however, elevated cholesterol levels were
found to be most strongly related to death from coronary disease and to
all-cause mortality in persons who were 65 years of age or more. CONCLUSIONS:
Patients who have recovered from a myocardial infarction and who have high
cholesterol levels are at an increased long-term risk for reinfarction, death
from coronary heart disease, and all-cause mortality. Our results confirm the
prognostic value of cholesterol levels measured after myocardial infarction and
support the role of lipid management in this population.
- Wong ND; Wilson PW; Kannel WB.
- Serum cholesterol as a prognostic factor after myocardial infarction: the
Framingham Study [see comments].
- Annals of Internal Medicine, 1991 Nov 1, 115(9):687-93. (UI: 92027249)
prognostic value of abnormalities on the electrocardiogram (ECG) present 1 year
after initial myocardial infarction (MI) is examined in relation to reinfarction
and coronary death throughout 32 years (mean, 10.1 years) of follow-up in the
Framingham Heart Study. Resting 12-lead ECGs were available in 251 survivors
(190 men and 61 women) of clinically recognized Q wave MI. The ECG reverted to
normal in 31 (12.4%) cases and was abnormal but without Q waves in 37 (14.7%). Q
waves persisted without other significant abnormalities in 108 (43.0%) and with
other abnormalities in 75 (29.9%) cases. Electrocardiographic abnormalities at
follow-up were more common in women and in those persons whose initial MI was
anterior as compared with inferior. Nonspecific T wave, ST segment changes, and
electrocardiographic left ventricular hypertrophy on the ECG before or after MI
were powerful predictors (p less than 0.01) of coronary death. The relation of
these residual post-MI electrocardiographic findings to reinfarction and
coronary death was assessed by Cox regression analysis. The follow-up
electrocardiographic status was unrelated to the risk of subsequent
reinfarction. Subjects who lost Q wave evidence of MI but whose ECG continued to
show evidence of repolarization abnormalities, left ventricular hypertrophy, or
blocked intraventricular conduction were at a 3.5-fold increased risk (p less
than 0.01) of coronary death as compared with those reverting to a normal ECG.
Persons with a persistent Q wave MI accompanied by these abnormalities were at a
2.7-fold excess risk (p = subsequent reinfarction. Subjects who lost Q wave
evidence of MI but whose ECG continued to show evidence of repolarization
abnormalities, left ventricular hypertrophy, or blocked intraventricular
conduction were at a 3.5-fold increased risk (p less than 0.01) of coronary
death as compared with those reverting to a normal ECG. Persons with a
persistent Q wave MI accompanied by these abnormalities were at a 2.7-fold
excess risk (p = 0.01) of coronary death as compared with those with a
normalized ECG. These findings remained significant when considering age and
standard coronary risk factors. The presence of other electrocardiographic
abnormalities without persistent Q waves yields a worse prognosis than a Q wave
persisting alone. The prognostic value of a follow-up ECG with abnormalities
other than a persistent Q wave MI also remained after considering the effects of
left ventricular hypertrophy and cardiac enlargement on x-ray, functional
classification, and diuretic usage. Specific electrocardiographic abnormalities
present before infarction, however, were potent indicators of long-term
prognosis prognosis and diminished the importance of the follow-up ECG. Although
survival after initial MI is improved only if the ECG reverts to normal,
information on electrocardiographic abnormalities before MI can be especially
useful in evaluating long-term risk.
- Wong ND; Levy D; Kannel WB.
- Prognostic significance of the electrocardiogram after Q wave myocardial
infarction. The Framingham Study.
- Circulation, 1990 Mar, 81(3):780-9. (UI: 90167989)
Last Updated Decemberb 18, 1998