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Circulation. 2004;109:1101-1107.

Clinical Investigation and Reports

Explaining the Decline in Coronary Heart Disease Mortality in England and Wales Between 1981 and 2000

Belgin Unal, MD, MPH; Julia Alison Critchley, DPhil; Simon Capewell, MD

From the Department of Public Health, University of Liverpool, England (B.U., J.A.C., S.C.), and the Department of Public Health, Dokuz Eylul University School of Medicine, Izmir, Turkey (B.U.).

Correspondence to Dr Belgin Unal, Dokuz Eylul University School of Medicine Department of Public Health, Izmir, Turkey. E-mail belgina@liv.ac.uk

Received August 6, 2003; revision received October 18, 2003; accepted October 18, 2003.

Background- Coronary heart disease mortality rates have been decreasing in the United Kingdom since the 1970s. Our study aimed to examine how much of the decrease in England and Wales between 1981 and 2000 could be attributed to medical and surgical treatments and how much to changes in cardiovascular risk factors.

Methods and Results- The IMPACT mortality model was used to combine and analyze data on uptake and effectiveness of cardiological treatments and risk factor trends in England and Wales. The main data sources were published trials and meta-analyses, official statistics, clinical audits, and national surveys. Between 1981 and 2000, coronary heart disease mortality rates in England and Wales decreased by 62% in men and 45% in women 25 to 84 years old. This resulted in 68 230 fewer deaths in 2000. Some 42% of this decrease was attributed to treatments in individuals (including 11% to secondary prevention, 13% to heart failure treatments, 8% to initial treatments of acute myocardial infarction, and 3% to hypertension treatments) and 58% to population risk factor reductions (principally smoking, 48%; blood pressure, 9.5%; and cholesterol, 9.5%). Adverse trends were seen for physical activity, obesity and diabetes.

Conclusions- More than half the coronary heart disease mortality decrease in Britain between 1981 and 2000 was attributable to reductions in major risk factors, principally smoking. This emphasizes the importance of a comprehensive strategy that promotes primary prevention, particularly for tobacco and diet, and that maximizes population coverage of effective treatments, especially for secondary prevention and heart failure. These findings may be cautiously generalizable to the United States and other developed countries. *

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Lancet. 1998 May 2;351(9112):1308-11.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9643792

Effect of breathing rate on oxygen saturation and exercise performance in chronic heart failure.

Bernardi L, Spadacini G, Bellwon J, Hajric R, Roskamm H, Frey AW.

Department of Internal Medicine, IRCCS S Matteo, University of Pavia, Italy. LBern1ps@ipv36.unipv.it

BACKGROUND: In chronic heart failure (CHF), impaired pulmonary function can independently contribute to oxygen desaturation and reduced physical activity. We investigated the effect of breathing rate on oxygen saturation and other respiratory indices. METHODS: Arterial oxygen saturation (SaO2) and respiratory indices were recorded during spontaneous breathing (baseline) and during controlled breathing at 15, six, and three breaths per min in 50 patients with CHF and in 11 healthy volunteers (controls). 15 patients with CHF were randomly allocated 1 month of respiratory training to decrease their respiratory rate to six breaths per min. Respiratory indices were recorded before training, at the end of training, and 1 month after training. FINDINGS: During spontaneous breathing, mean SaO2 was lower in CHF patients than in controls (91-4% [SD 0.4] vs 95.4% [0.2], p<0.001). Controlled breathing increased SaO2 at all breathing rates in patients with CHF. Compared with baseline, minute ventilation increased at 15 breaths per min (+45.9% [9.8], p<0.01), did not change at six breaths per min, and decreased at three breaths per min (-40.3% [4.8], p<0.001). In the nine CHF patients who had 1 month of respiratory training, resting SaO2 increased from 92.5% (0.3) at baseline to 93.2% (0.4) (p<0.05), their breathing rate per min decreased from 13.4 (1.5) to 7.6 (1.9) (p<0.001), peak oxygen consumption increased from 1157 (83) to 1368 (110) L/min (p<0.05), exercise time increased from 583 (29) to 615 (23) min/s (p<0.05), and perception of dyspnoea reduced from a score of 19.0 (0.4) to 17.3 (0.9) on the Borg scale (p<0.05). There were no changes in the respiratory indices in the patients who did not have respiratory training. INTERPRETATION: Slowing respiratory rate reduces dyspnoea and improves both resting pulmonary gas exchange and exercise performance in patients with CHF.*

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Circulation. 2002;105:143.)

Brief Rapid Communications

Slow Breathing Increases Arterial Baroreflex Sensitivity in Patients With Chronic Heart Failure

Luciano Bernardi, MD; Cesare Porta, MD; Lucia Spicuzza, MD; Jerzy Bellwon, MD; Giammario Spadacini, MD; Axel W. Frey, MD; Leata Y.C. Yeung, MD; John E. Sanderson, MD; Roberto Pedretti, MD; Roberto Tramarin, MD

From the Department of Internal Medicine, University of Pavia and IRCCS Ospedale S Matteo, (L.B., C.P.), Pavia, Italy; the Institute of Respiratory Diseases, University of Catania (L.S.), Catania, Italy; First Department of Cardiology, University of Gdansk (J.B.), Gdansk, Poland; Herz-Zentrum (G.M., A.W.F.), Bad Krozingen, Germany; the Chinese University of Hong Kong, Prince of Wales Hospital (L.Y.C.Y., J.E.S.), Hong Kong SAR; the Department of Cardiology, IRCCS Fondazione Salvatore Maugeri, Centro Medico Tradate (R.P.), Tradate, Italy; and the Department of Cardiology, IRCCS Fondazione Salvatore Maugeri, Centro Medico Pavia (R.T.), Pavia, Italy.

Correspondence to Luciano Bernardi, MD, Clinica Medica 1, Universita' di Pavia, IRCCS Ospedale S Matteo, 27100 Pavia, Italy. E-mail lbern1ps@unipv.it

Background- It is well established that a depressed baroreflex sensitivity may adversely influence the prognosis in patients with chronic heart failure (CHF) and in those with previous myocardial infarction.

Methods and Results- We tested whether a slow breathing rate (6 breaths/min) could modify the baroreflex sensitivity in 81 patients with stable (2 weeks) CHF (age, 58±1 years; NYHA classes I [6 patients], II [33], III [27], and IV [15]) and in 21 controls. Slow breathing induced highly significant increases in baroreflex sensitivity, both in controls (from 9.4±0.7 to 13.8±1.0 ms/mm Hg, P<0.0025) and in CHF patients (from 5.0±0.3 to 6.1±0.5 ms/mm Hg, P<0.0025), which correlated with the value obtained during spontaneous breathing (r=+0.202, P=0.047). In addition, systolic and diastolic blood pressure decreased in CHF patients (systolic, from 117±3 to 110±4 mm Hg, P=0.009; diastolic, from 62±1 to 59±1 mm Hg, P=0.02).

Conclusions- These data suggest that in patients with CHF, slow breathing, in addition to improving oxygen saturation and exercise tolerance as has been previously shown, may be beneficial by increasing baroreflex sensitivity.

Key Words: baroreflex • heart failure • heart rate • blood pressure • respiration *

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Circulation. 2003;108:2757.)

Clinical Investigation and Reports

Relation Between Progression and Regression of Atherosclerotic Left Main Coronary Artery Disease and Serum Cholesterol Levels as Assessed With Serial Long-Term (9-18 Months) Follow-Up Intravascular Ultrasound

Clemens von Birgelen, MD, PhD; Marc Hartmann, MD; Gary S. Mintz, MD; Dietrich Baumgart, MD; Axel Schmermund, MD; Raimund Erbel, MD

From the Department of Cardiology, Essen University, Essen, Germany (C.v.B., M.H., D.B., A.S., R.E.); the Department of Cardiology, Medisch Spectrum Twente, Enschede, the Netherlands (C.v.B.); and the Cardiovascular Research Foundation, New York, NY (G.S.M.).

Correspondence to Dr Clemens von Birgelen, Medisch Spectrum Twente, Enschede Hospital, Cardiology Department, Ariensplein 1, 7511 JX Enschede, The Netherlands. E-mail von.birgelen@freeler.nl

Received May 28, 2003; revision received September 4, 2003; accepted September 8, 2003.

Background- The relation between serum lipids and risk of coronary events has been established, but there are no data demonstrating directly the relation between serum low-density lipoprotein (LDL) cholesterol and high-density lipoprotein (HDL) cholesterol versus serial changes in coronary plaque dimensions.

Methods and Results- We performed standard analyses of serial intravascular ultrasound (IVUS) studies of 60 left main coronary arteries obtained 18.3±9.4 months apart to evaluate progression and regression of mild atherosclerotic plaques in relation to serum cholesterol levels. Overall, there was (1) a positive linear relation between LDL cholesterol and the annual changes in plaque plus media (P&M) cross-sectional area (CSA) (r=0.41, P<0.0001) with (2) an LDL value of 75 mg/dL as the cutoff when regression analysis predicted on average no annual P&M CSA increase; (3) an inverse relation between HDL cholesterol and annual changes in P&M CSA (r=-0.30, P<0.02); (4) an inverse relation between LDL cholesterol and annual changes in lumen CSA (r=-0.32, P<0.01); and (5) no relation between LDL and HDL cholesterol and the annual changes in total arterial CSA (remodeling). Despite similar baseline IVUS characteristics, patients with an LDL cholesterol level <120 mg/dL showed more annual P&M CSA progression and lumen reduction than patients with lower LDL cholesterol.

Conclusions- There is a positive linear relation between LDL cholesterol and annual changes in plaque size, with an LDL value of 75 mg/dL predicting, on average, no plaque progression. HDL cholesterol shows an inverse relation with annual changes in plaque size.

Key Words: ultrasonics • coronary disease • cholesterol • lipids *

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American Journal of Clinical Nutrition, Vol. 74, No. 1, 1-2, July 2001

Editorial

The public health implications of the Dietary Approaches to Stop Hypertension Trial 1,2

For study purposes it is highly recommended to go to the original article at http://www.ajcn.org/cgi/content/full/74/1/1 and use references and their links to online free texts

George Lburn Black¹

1 From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston.

2 Reprints not available. Address correspondence to GL Blackburn, Beth Israel Deaconess Medical Center, Harvard Medical School, 1 Autumn Street, Kennedy 152, Boston, MA 02215. E-mail: gblackbu@caregroup.harvard.edu. RFN2

The Dietary Approaches to Stop Hypertension (DASH) Trial was designed to assess the relation between modification of dietary patterns and hypertension (1, 2). DASH provides evidence that existing dietary recommendations can produce concrete health results in a relatively healthy but sedentary population in which 50% of the participants were women and 60% were African American. Obarzanek et al (3) applied the Framingham risk equation (4) to the results of their study published in this issue of the Journal to estimate 10-y risk of coronary heart disease (CHD) in subjects consuming the recommended DASH diet. The results showed a 12.1% decreased risk of CHD in the participants consuming the DASH diet compared with a slightly increased risk in those consuming the control diet. The decrease was achieved in the absence of changes in weight or physical activity. Reductions in blood lipids were greater in men than in women, whereas the lipid response to diet did not differ significantly between African Americans and non-African Americans.

Data from DASH and other clinical trials offer the most significant evidence to date of the role of diet in health promotion, disease prevention, and disease treatment (5-7). These studies underscore the messages in the new Dietary Guidelines for Americans (8). The DASH diet and similar dietary patterns that include low-fat dairy products and a high intake of fruit, vegetables, and fiber provide important guidelines for public health policy (9, 10). Other lifestyle factors-such as physical activity levels, annual physical exams, immunizations, monitoring of vital signs, and other preventive health measures-might also affect outcomes. This may be particularly true for exercise, which can be expected to raise HDL cholesterol and lower triacylglycerol, results not achieved by the DASH diet alone. Weight loss can also be expected to potentiate the outcomes.

The lipid biomarkers of CHD risk are well established (4, 6, 7, 11), as are the salubrious effects of diets that include low-fat dairy products and certain fruit and vegetables, including legumes, potatoes, juices, apples, bananas, oranges, lettuce, spinach, string beans, and tomatoes. Absence of information on various fruit and vegetables, however, may be especially problematic if only certain types and diversities confer protection, eg, spinach, Brussels sprouts, broccoli, and string beans, which are particularly nutrient dense and require little insulin for their digestion and metabolism.

Dietary patterns are influenced by cultural, ethnic, and environmental factors, including the availability of foods, the ability to purchase and prepare foods, and food industry advertising. Dietary patterns are also not readily altered, and the major limitation of the DASH study is the questionable ability of most persons to maintain dietary changes in the long term.

The DASH diet requires twice the average daily servings of fruit, vegetables, and dairy products; one-third the usual intake of beef, pork, and ham; one-half the typical use of fats, oils, and salad dressings; and one-quarter the ordinary number of snacks and sweets. It also requires education for lactose-intolerant individuals on the use of lactase enzyme products and behavior modification to help change lifelong eating habits. The volume of food consumed from the 5 major food groups of the DASH diet is 1.94 kg (68.5 oz), whereas only 51 g (1.8 oz) comes from fats and sugars. This is twice the volume of healthful food and a fraction of the energy-dense, nutrient-poor junk food found in a typical Western diet (1, 10, 12).

According to public health researchers, those who make small, incremental changes in their diet over time have the highest probability of success. Recommendations include considering meat as just one part of a meal; centering food choices around carbohydrates such as pasta, rice, beans, or vegetables; and replacing traditional snacks and desserts with fruit or low-fat, low-energy foods such as sugarless gelatin. Portion-controlled foods and liquid meal replacement represent a new approach to healthful eating (5-7, 11).

Current clinical studies targeted to changes in diet and exercise patterns stress the importance of these community and individual challenges. However, long-term results do not bode well for healthful diets according to the results of DASH (9, 10). Nevertheless, DASH and other dietary pattern trials have provided significant knowledge on the role of diet in preventing chronic disease. It is incumbent on us to use that knowledge in the interest of public health (13).

The need to develop a simple, modern diet as effective as the DASH diet is one of the major challenges facing food technologists and nutrition scientists (13, 14). It is also an extraordinary opportunity for improving public health by broadening the appeal and use of scientifically sound functional foods. Tucker et al (15), for example, describes relations among consumption of whole grains, vegetables, fruit, and fish and the inverse association of these foods with meat. Fung et al (10) advanced this approach by examining the relation between 2 dietary patterns, a so-called prudent pattern and a Western pattern, and biomarkers of cardiovascular disease risk. This scientific approach, which used factor analysis, provided added evidence that dietary patterns can be related to measures of health. Other studies that used cluster analysis reached the same conclusion, particularly when the cohort was well defined and restricted to one population. The Healthy Eating Index, a comprehensive measure of diet quality, combines multiple aspects of diet in relation to guidelines into a single score (16).

We need to develop simple and clear food-selection tools that will meet the recommendations of the Dietary Guidelines for Americans. Evidence from DASH and similar controlled studies provides proof of the value of scientifically sound food selection, but there is a lack of science on which community strategies or individual interventions can be based. Our diverse society requires innovation in food delivery, convenience, and culture-changes that will deliver measurable improvements in compliance to new dietary patterns and in quality of life.

REFERENCES

1. Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997; 336:1117-24.

2. Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 2001;344:3-10.

3. Obarzanek E, Sacks FM, Vollmer WM, et al. Effects on blood lipids of a blood pressure-lowering diet: the Dietary Approaches to Stop Hypertension (DASH) Trial. Am J Clin Nutr 2001;74:80-9.

4. Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation 1998;97:1837-47.

5. Metz JA, Stern JS, Kris-Etherton P, et al. A randomized trial of improved weight loss with a prepared meal plan in overweight and obese patients: impact on cardiovascular risk reduction. Arch Intern Med 2000;160:2150-8.

6. Chait A, Malinow MR, Nevin DN, et al. Increased dietary micronutrients decrease serum homocysteine concentrations in patients at high risk of cardiovascular disease. Am J Clin Nutr 1999;70:881-7.

7. Haynes RB, Kris-Etherton P, McCarron DA, et al. Nutritionally complete prepared meal plan to reduce cardiovascular risk factors: a randomized clinical trial. J Am Diet Assoc 1999;99:1077-83.[Medline]

8. US Department of Health and human Services, US Department of Agriculture. Dietary guidelines for Americans. 5th ed. Washington, DC: US Government Printing Office, 2000.

9. Kant AK, Schatzkin A, Graubard BI, Schairer C. A prospective study of diet quality and mortality in women. JAMA 2000;283: 2109-15.

10. Fung TT, Rimm EB, Spiegelman D, et al. Association between dietary patterns and plasma biomarkers of obesity and cardiovascular disease risk. Am J Clin Nutr 2001;73:61-7.

11. Ditschuneit HH, Flechtner-Mors M, Johnson TD, Adler G. Metabolic and weight-loss effects of a long-term dietary intervention in obese patients. Am J Clin Nutr 1999;69:198-204.

12. Kant AK. Consumption of energy-dense, nutrient-poor foods by adult Americans: nutritional and health implications. The third National Health and Nutrition Examination Survey, 1988-1994. Am J Clin Nutr 2000;72:929-36.

13. Blackburn GL. Functional foods in the prevention and treatment of disease: significance of the Dietary Approaches to Stop Hypertension Study. Am J Clin Nutr 1997;66:1067-71.

14. French SA, Jeffery RW, Story M, et al. Pricing and promotion effects on low-fat vending snack purchases: the CHIPS Study. Am J Public Health 2001;91:112-7.

15. Tucker KL, Dallal GE, Rush D. Dietary patterns of elderly Boston-area residents defined by cluster analysis. J Am Diet Assoc 1992;92: 1487-91.

Kennedy ET, Phis J, Carlson S, Fleming K. The Healthy Eating Index: design and application. J Am Diet Assoc 1995;95:1103-8. *

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Prev Med. 2000 Apr;30(4):277-81

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ uids=10731455&dopt=Citation

Training effects of accumulated daily stair-climbing exercise in previously sedentary young women.

Boreham CA, Wallace WF, Nevill A.

Sports Studies, University of Ulster at Jordanstown, Jordanstown, Country Antrim, BT37 OQB, United Kingdom. ca.boreham@ulst.ac.uk

BACKGROUND: The health and fitness benefits associated with short, intermittent bouts of exercise accumulated throughout the day have been seldom investigated. Stair climbing provides an ideal model for this purpose. METHODS: Twenty-two healthy female volunteers (18-22 years) were randomly assigned to control (N = 10) or stair-climbing (N = 12) groups. Stair climbers then underwent a 7-week stair-climbing program, progressing from one ascent per day in week 1 to six ascents per day in weeks 6 and 7, using a public access staircase (199 steps). Controls were instructed to maintain their normal lifestyle. Standardized stair-climbing tests were administered to both groups immediately before and after the program. Each paced ascent lasted 135 s, during which oxygen uptake (VO(2)) and heart rate (HR) were monitored continuously. Blood lactate concentration was also measured immediately following each test ascent. Fasting blood samples from before and after the program were analyzed for serum lipids. Data were analyzed using a two-way ANOVA with repeated measures. RESULTS: Relative to the insignificant changes in the control group, the stair-climbing group displayed a rise in HDL cholesterol concentration (P<0.05) and a reduced total:HDL ratio (P<0.01) over the course of the program. VO(2) and HR during the stair-climbing test were also reduced, as was blood lactate (all P<0.01). CONCLUSION: A short-term stair-climbing program can confer considerable cardiovascular health benefits on previously sedentary young women, lending credence to the potential public health benefits of this form of exercise. Copyright 2000 American Health Foundation and Academic Press. *

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New England Journal of Medicine Volume 342:1392-1398 May 11, 2000 Number 19

Beneficial Effects of High Dietary Fiber Intake in Patients with Type 2 Diabetes Mellitus

Manisha Chandalia, M.D., Abhimanyu Garg, M.D., Dieter Lutjohann, Ph.D., Klaus von Bergmann, M.D., Scott M. Grundy, M.D., Ph.D., and Linda J. Brinkley, R.D.

http://content.nejm.org/cgi/content/abstract/342/19/1392?firstpage=1392&volume=342&sendit=GO&searchid=1091433117318_830&FIRSTINDEX =0&volume=342&firstpage=1392&journalcode=nejm

For comment http://www.medscape.com/viewarticle/418629

ABSTRACT

Background The effect of increasing the intake of dietary fiber on glycemic control in patients with type 2 diabetes mellitus is controversial.

Methods In a randomized, crossover study, we assigned 13 patients with type 2 diabetes mellitus to follow two diets, each for six weeks: a diet containing moderate amounts of fiber (total, 24 g; 8 g of soluble fiber and 16 g of insoluble fiber), as recommended by the American Diabetes Association (ADA), and a high-fiber diet (total, 50 g; 25 g of soluble fiber and 25 g of insoluble fiber) containing foods not fortified with fiber (unfortified foods). Both diets, prepared in a research kitchen, had the same macronutrient and energy content. We compared the effects of the two diets on glycemic control and plasma lipid concentrations.

Results Compliance with the diets was excellent. During the sixth week of the high-fiber diet, as compared with the sixth week of the ADA diet, mean daily preprandial plasma glucose concentrations were 13 mg per deciliter (0.7 mmol per liter) lower (95 percent confidence interval, 1 to 24 mg per deciliter [0.1 to 1.3 mmol per liter]; P=0.04) and mean daily urinary glucose excretion was 1.3 g lower (median difference, 0.23 g; 95 percent confidence interval, 0.03 to 1.83; P=0.008). The high-fiber diet also lowered the area under the curve for 24-hour plasma glucose and insulin concentrations, which were measured every two hours, by 10 percent (P=0.02) and 12 percent (P=0.05), respectively. The high-fiber diet reduced plasma total cholesterol concentrations by 6.7 percent (P=0.02), triglyceride concentrations by 10.2 percent (P=0.02), and very-low-density lipoprotein cholesterol concentrations by 12.5 percent (P=0.01).

Conclusions A high intake of dietary fiber, particularly of the soluble type, above the level recommended by the ADA, improves glycemic control, decreases hyperinsulinemia, and lowers plasma lipid concentrations in patients with type 2 diabetes.

Source Information

From the Department of Internal Medicine (M.C., A.G., S.M.G., L.J.B.) and the Center for Human Nutrition (A.G., S.M.G.), University of Texas Southwestern Medical Center, Dallas; the Department of Veterans Affairs Medical Center, Dallas (M.C., A.G., S.M.G.); and the Department of Clinical Pharmacology, Rheinische Friedrich-Wilhelms-Universität, Bonn, Germany (D.L., K.B.).

Address reprint requests to Dr. Garg at the Center for Human Nutrition, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390. *

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December 2004 J Am Dietetic Assoc Volume 104 Number 12

Diets lower in folic acid and carotenoids are associated with the coronary disease epidemic in Central and Eastern Europe

Sonja L. Connor, MS, RD *

Lila S. Ojeda, MS, RD

Gary Sexton, PhD

Gerdi Weidner, PhD

William E. Connor, MD

Abstract

Objective To test our hypothesis that lower intakes of previously identified cardioprotective nutrients would be associated with the coronary epidemic in Central and Eastern Europe.

Design We conducted a survey of coronary mortality in 16 countries and diet in 19 countries.

Subjects/setting Countries were placed in four groups with different cultural patterns (Central and Eastern Europe, including Russia; Western Europe and the United States; Mediterranean; and Asian).

Main outcome measures Independent predictors of coronary mortality.

Statistical analyses performed Means and standard deviations were calculated, and analysis of variance with Bonferroni post hoc tests and backward elimination regression analysis was conducted.

Results Coronary mortality was highest in Central and Eastern Europe followed by Western Europe and the United States, the Mediterranean countries, and Asia (Japan). The model with folate, fiber, and n-6/n-3 fatty acids explained the majority of variation in coronary mortality (men 86%, women 90%). Most of the variation was explained by folate (men 61%, women 62%). The picture is complicated by the fact that folate, lutein/zeaxanthin, and beta-carotene were highly intercorrelated (r=0.87 to 0.99).

Conclusions A diet low in foods containing folate and carotenoids (beta-carotene and lutein/zeaxanthin) may be a major contributing factor to increased coronary risk observed in the countries of Central and Eastern Europe.

*Address correspondence to: Sonja L. Connor, MS, RD, Research Associate Professor, Department of Medicine, Oregon Health and Science University: L465, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098.

Email address: connors@ohsu.edu (Sonja L. Connor)

Copyright (c) by American Dietetic Association doi: 10.1016/j.jada.2004.09.023

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Circulation. 2004;110:1236-1244.)

Original Articles

Explaining the Increase in Coronary Heart Disease Mortality in Beijing Between 1984 and 1999

Julia Critchley, MSc, DPhil; Jing Liu, MD, MPH; Dong Zhao, MD, PhD; Wang Wei, MD; Simon Capewell, FRCPE

From International Health Research Group (J.C.), Liverpool School of Tropical Medicine, Liverpool, UK; Department of Epidemiology (J.L., D.Z., W.W.), Beijing Institute of Heart, Lung & Blood Vessel Diseases, Beijing, China; and Department of Public Health (S.C.), University of Liverpool, Liverpool, UK.

Correspondence to Dr Julia Critchley, International Health Research Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK. E-mail juliac@liverpool.ac.uk

Received January 8, 2004; revision received May 12, 2004; accepted May 21, 2004.

Background- Coronary heart disease (CHD) mortality is rising in many developing countries. We examined how much of the increase in CHD mortality in Beijing, China, between 1984 and 1999 could be attributed to changes in major cardiovascular risk factors and assessed the impact of medical and surgical treatments.

Methods and Results- A validated, cell-based mortality model synthesized data on (1) patient numbers, (2) uptake of specific medical and surgical treatments, (3) treatment effectiveness, and (4) population trends in major cardiovascular risk factors (smoking, total cholesterol, blood pressure, obesity, and diabetes). Main data sources were the WHO MONICA and Sino-MONICA studies, the Chinese Multi-provincial Cohort Study, routine hospital statistics, and published meta-analyses. Age-adjusted CHD mortality rates increased by 50% in men and 27% in women (1608 more deaths in 1999 than expected by application of 1984 rates). Most of this increase (77%, or 1397 additional deaths) was attributable to substantial rises in total cholesterol levels (more than 1 mmol/L), plus increases in diabetes and obesity. Blood pressure decreased slightly, whereas smoking prevalence increased in men but decreased substantially in women. In 1999, medical and surgical treatments in patients together prevented or postponed 642 deaths, mainly from initial treatments for acute myocardial infarction (41%), hypertension (24%), angina (15%), secondary prevention (11%), and heart failure (10%). Multiway sensitivity analyses did not greatly influence the results.

Conclusions- Much of the dramatic CHD mortality increases in Beijing can be explained by rises in total cholesterol, reflecting an increasingly "Western" diet. Without cardiological treatments, increases would have been even greater.

Key Words: coronary disease mortality risk factors prevention *

(A10)

Circulation. 2001;104:2018.)

Reducing Emotional Distress Improves Prognosis in Coronary Heart Disease 9-Year Mortality in a Clinical Trial of Rehabilitation

Johan Denollet, PhD; Dirk L. Brutsaert, MD

From the Department of Clinical Health Psychology, Tilburg University, the Netherlands (J.D.), and the Center for Cardiac Rehabilitation, University Hospital of Antwerp, Belgium (J.D., D.L.B.).

Correspondence to Johan Denollet, PhD, Clinical Health Psychology, Room P508, Tilburg University, Warandelaan, 2, PO Box 90153, 5000 LE Tilburg, the Netherlands. E-mail j.denollet@kub.nl

Background- The impact of treating emotional distress on prognosis in coronary heart disease (CHD) has not been documented convincingly. We tested the hypothesis that treatment-related changes in emotional distress may explain the beneficial effect of rehabilitation on prognosis.

Methods and Results- In this nonrandomized clinical trial, 150 men with CHD participated in rehabilitation (n=78) or received standard medical care (n=72). There were no differences between rehabilitation and control patients with regard to left ventricular ejection fraction (LVEF) or standard care. End points were reduction in distress after 3 months and mortality after 9 years. At the end of the 3-month trial, 64 patients (43%) reported improvement and 22 (15%) reported deterioration in negative affect. Rehabilitation patients improved more (P=0.004) and deteriorated less (P=0.001) than control patients; rehabilitation was effective in reducing distress. After 9 years of follow-up, 15 patients had died (13 cardiac and 2 cancer deaths). Mortality was associated with LVEF 50% (P=0.038) and deterioration in negative affect (P=0.007). Rate of death was 17% (12/72) for control patients versus 4% (3/78) for rehabilitation patients (P=0.009); rehabilitation was effective in reducing mortality. LVEF 50% (OR 3.2; 95% CI 1.1 to 9.8; P=0.041) and rehabilitation (OR 0.2; 95% CI 0.1 to 0.7; P=0.016) were independent predictors of mortality. Rehabilitation warded off the deleterious effect of deterioration in negative affect on prognosis.

Conclusions- Deterioration in negative affect is associated with a high long-term mortality risk. Warding off deterioration in negative affect is a mechanism that may explain the beneficial effect of comprehensive rehabilitation on prognosis in patients with CHD.

Key Words: myocardial infarction • mortality • stress • depression • trials *

(A11)

Circulation. 2004;110:3599-3603.

Vascular Medicine

Postprandial Hypertriglyceridemia Increases Circulating Levels of Endothelial Cell Microparticles

Alexandre C. Ferreira, MD; Arley A. Peter, MD; Armando J. Mendez, PhD; Joaqu¡n J. Jimenez, MD; Lucia M. Mauro; Julio A. Chirinos, MD; Reyan Ghany, MD; Salim Virani, MD; Santiago Garcia, MD; Lawrence L. Horstman; Joshua Purow, MD; Wenche Jy, PhD; Yeon S. Ahn, MD; Eduardo de Marchena, MD

From the University of Miami School of Medicine, Cardiovascular Center (A.C.F., A.A.P., J.A.C., R.G., S.V., S.G., L.L.H., J.P., E.D.M.), Diabetes Research Institute (A.J.M.), and Wallace H. Coulter Platelet Laboratory (J.J.J., L.M.M., W.J., Y.S.A.), Miami, Fla.

Correspondence to Alexandre Ferreira, MD, Director, Coronary Care Unit, Department of Medicine, Division of Cardiology, PO Box 016960, Miami, FL 33101. E-mail aferreir@med.miami.edu

Received April 15, 2004; revision received August 3, 2004; accepted August 12, 2004.

Background- This study evaluated a possible relationship between levels of endothelial microparticles (EMPs), known to be a sensitive indicator of endothelial disturbance, and changes in postprandial lipid levels in healthy volunteers after a low- or high-fat meal.

Methods and Results- Eighteen healthy subjects without known cardiovascular risk factors were evaluated. Lipid and EMP levels were measured before and 1 and 3 hours after a single low- or high-fat isocaloric meal. The low-fat meal had no significant postprandial effect on EMPs or lipids compared with fasting levels. In contrast, a single high-fat meal significantly increased EMP levels after 1 and 3 hours, from 389±54 (thousands per milliliter) when fasting to 541±139 (P=0.0002) and 677±159 (P<0.0001), respectively, and correlated with a postprandial elevation in serum triglycerides.

Conclusions- A single high-fat meal led to a significant elevation of plasma EMP levels in healthy, normolipidemic subjects and correlated with a postprandial elevation of serum triglycerides. EMPs may be an indirect marker of endothelial dysfunction or injury induced by postprandial triglyceride-rich lipoproteins.

Key Words: hypertriglyceridemia endothelium microparticles *

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For study purposes it is recommended you link to the original abstract and then use links to the rest of that particular issue / volume of the journal http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12831834

Brain Behav Immun. 2003 Aug;17(4):310-5.

Psychological factors correlate meaningfully with percent-monocytes among acute coronary syndrome patients.

Gidron Y, Armon T, Gilutz H, Huleihel M.

Department of Sociology of Health, Faculty of Health Sciences, Ben-Gurion University, Be'er-Sheva 84105, Israel. yorig@bgumail.bgu.ac.il

Recent research demonstrates the importance of inflammatory parameters in the etiology and prognosis of the acute coronary syndrome (ACS). This study explored relations between psychological factors and immunological parameters routinely measured among ACS patients. Forty-two ACS patients completed questionnaires assessing perceived-control, emotional support, hostility, and life-events 2-4 days after hospitalization. Data on total leukocytes and percentages (%) of monocytes, %neutrophils, and %lymphocytes upon admission to hospital were collected from computerized medical charts as well as various biomedical information and risk-factors (e.g., diagnosis, left-ventricle-LV functioning, smoking, and hypertension). Of all significant biomedical variables, LV-function and arrival-time correlated uniquely with total leukocytes. Controlling for LV-function and arrival-time, hostility and life-events positively correlated with %monocytes, and perceived-control and emotional-support inversely correlated with %monocytes. Emotional-support was positively correlated and life-events were negatively correlated with %neutrophils. Macrophages play a pivotal role in plaque instability, the trigger of an ACS. This initiating role, and our finding of a relationship between recruitment of monocytes and a poor psychosocial profile, predictive of ACS, are consistent with a PNI component in the pathophysiology of ACS. *

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J Am Coll Cardiol. 2003 Sep 3;42(5):861-872.

Anti-inflammatory effects of exercise training in the skeletal muscle of patients with chronic heart failure.

Gielen S, Adams V, Mobius-Winkler S, Linke A, Erbs S, Yu J, Kempf W, Schubert A, Schuler G, Hambrecht R.

Universitat Leipzig, Herzzentrum GmbH, Department of Internal Medicine & Cardiology, Strumpellstrasse 39, 04289 Leipzig, Germany.

OBJECTIVES: The aim of this study was to assess the effects of regular physical exercise on local inflammatory parameters in the skeletal muscle of patients with chronic heart failure (CHF).BACKGROUND: Inflammatory activation with increased serum cytokine levels and expression of inducible nitric oxide synthase (iNOS) in the myocardium and peripheral skeletal muscles has been described in CHF. METHODS: Twenty male patients with stable CHF (left ventricular ejection fraction 25 +/- 2%; age 54 +/- 2 years) were randomized to a training group (n = 10) or a control group (n = 10). At baseline and after six months, serum samples and vastus lateralis muscle biopsies were obtained. Serum tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and IL-1-beta levels were measured by enzyme-linked immunosorbent assay, local cytokine, and iNOS expression by real-time polymerase chain reaction. RESULTS: Exercise training improved peak oxygen uptake by 29% in the training group (from 20.3 +/- 1.0 to 26.1 +/- 1.5 ml/kg. min; p < 0.001 vs. control group). While serum levels of TNF-alpha, IL-6, and IL-1-beta remained unaffected by training, local skeletal muscle TNF-alpha decreased from 1.9 +/- 0.4 to 1.2 +/- 0.3 relative U (p < 0.05 for change vs. control group), IL-6 from 71.3 +/- 16.5 to 41.3 +/- 8.8 relative U (p < 0.05 vs. begin), and IL-1-beta from 2.7 +/- 1.1 to 1.4 +/- 0.6 relative U (p = 0.02 vs. control group). Exercise training also reduced local iNOS expression by 52% (from 6.3 +/- 1.2 to 3.0 +/- 1.0 relative U; p = 0.007 vs. control group). CONCLUSIONS: Exercise training significantly reduced the local expression of TNF-alpha, IL-1-beta, IL-6, and iNOS in the skeletal muscle of CHF patients. These local anti-inflammatory effects of exercise may attenuate the catabolic wasting process associated with the progression of CHF.

COMMENT

Anti-Inflammatory Effects of Exercise May Lessen CHF-Related Cardiac Skeletal Muscle Wasting

Aerobic exercise reduces levels of inflammatory cytokines in skeletal muscle of patients with chronic heart failure (CHF), researchers report in the September 3rd issue of the Journal of the American College of Cardiology.

These local anti-inflammatory effects of exercise may attenuate skeletal muscle wasting seen in patients with CHF.

"For patients with stable CHF, regular aerobic exercise training should not be regarded as rehabilitation only, but as a continuing treatment with the potential to modify the underlying disease process," Dr. Stephan Gielen of the University of Leipzig Heart Center in Germany said in a statement.

Dr. Gielen and colleagues randomly assigned 20 men with stable CHF to a control group or to an exercise-training group for 6 months. Men in the training group participated in group workouts and rode a stationary bicycle daily for 20 minutes at workloads corresponding to 70% of maximal oxygen uptake during symptom-limited exercise.

At baseline, local expression of TNF-alpha, IL-1-beta, and IL-6 was significantly increased in skeletal muscle relative to serum levels of these cytokines, which were only slightly higher than normal.

Six months of regular exercise led to a significant reduction in skeletal muscle TNF-alpha, IL-1-beta, and IL-6, while serum levels of these cytokines remained virtually unchanged. Specifically, TNF-alpha fell from 1.9 to 1.2 U (p < 0.05 for change vs. control), IL-1-beta from 2.7 to 1.4 U (p = 0.02 vs. control), and IL-6 from 71.3 to 41.3 U (p < 0.05 vs. baseline).

Exercise training also reduced local inducible nitric oxide synthase (iNOS) expression by 52%.

There was no change in TNF-alpha, IL-1-beta, and IL-6 or iNOS in the control group.

Consistent with previous reports, exercise training also improved peak oxygen uptake by 29%.

"Taken together, these results indicate that long-term aerobic endurance training in CHF patients has anti-inflammatory effects on the skeletal muscle," Dr. Gielen and colleagues write. "These local anti-inflammatory effects of exercise may attenuate the catabolic wasting process associated with the progression of CHF.*

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Circulation. 2003;108:530.)

Effect of Different Intensities of Exercise on Endothelium-Dependent Vasodilation in Humans Role of Endothelium-Dependent Nitric Oxide and Oxidative Stress

Chikara Goto, RPT, MS; Yukihito Higashi, MD, PhD; Masashi Kimura, MD; Kensuke Noma, MD; Keiko Hara, MD; Keigo Nakagawa, MD; Mitsutoshi Kawamura, RPT, MS; Kazuaki Chayama, MD, PhD; Masao Yoshizumi, MD, PhD; Isao Nara, RPT, PhD

From the Program in Physical Therapy Health Sciences, School of Medicine (C.G., M.K., I.N.), Department of Cardiovascular Physiology and Medicine (Y.H., M.Y.), Department of Medicine and Molecular Science (K. Noma, M.K., K.H., K. Nakagawa, K.C.), Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan.

Correspondence to Yukihito Higashi, MD, PhD, FAHA, Department of Cardiovascular Physiology and Medicine, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan. E-mail yhigashi@hiroshima-u.ac.jp

Received June 11, 2002; de novo received February 19, 2003; revision received May 5, 2003; accepted May 5, 2003.

Background- Aerobic exercise enhances endothelium-dependent vasodilation in hypertensive patients, patients with chronic heart failure, and healthy individuals. However, it is unclear how the intensity of exercise affects endothelial function in humans. The purpose of the present study was to determine the effects of different intensities of exercise on endothelium-dependent vasodilation in humans.

Methods and Results- We evaluated the forearm blood flow responses to acetylcholine, an endothelium-dependent vasodilator, and isosorbide dinitrate, an endothelium-independent vasodilator, before and after different intensities of exercise (mild, 25% O2max; moderate, 50% O2max; and high, 75% O2max; bicycle ergometers, 30 minutes, 5 to 7 times per week for 12 weeks) in 26 healthy young men. Forearm blood flow was measured using a mercury-filled Silastic strain-gauge plethysmograph. Twelve weeks of moderate-intensity exercise, but not mild- or high-intensity exercise, significantly augmented acetylcholine-induced vasodilation (7.5±2.4 to 11.4±5.8 mL/min per 100 mL tissue; P<0.05). No intensity of aerobic exercise altered isosorbide dinitrate-induced vasodilation. The administration of NG-monomethyl-L-arginine, a nitric oxide synthase inhibitor, abolished the moderate-intensity exercise-induced augmentation of the forearm blood flow response to acetylcholine. High-intensity exercise increases plasma concentrations of 8-hydroxy-2'-deoxyguanosine (from 6.7±1.1 to 9.2±2.3 ng/mL; P<0.05) and serum concentrations of malondialdehyde-modified low-density lipoprotein (from 69.0±19.5 to 82.4±21.5 U/L; P<0.05), whereas moderate exercise tended to decrease both indices of oxidative stress.

Conclusions- These findings suggest that moderate-intensity aerobic exercise augments endothelium-dependent vasodilation in humans through the increased production of nitric oxide and that high-intensity exercise possibly increases oxidative stress. *

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Circulation. 2003;108:292.)

Clinical Investigation and Reports

Variability of Phase Shift Between Blood Pressure and Heart Rate Fluctuations A Marker of Short-Term Circulation Control

Josef Halámek, PhD; Tomá Kára, MD; Pavel Jurák, PhD; Miroslav Souek, MD, PhD; Darrel P. Francis, MD, MRCP; L. Ceri Davies, MD, MRCP; Win K. Shen, MD, PhD; Andrew J.S. Coats, DM, FRCP; Miroslav Novák, MD, PhD; Zuzana Nováková, MD, PhD; Roman Panovsk, MD; Jií Toman, MD, PhD; Josef umbera, MD, PhD; Virend K. Somers, MD, PhD

From the Institute of Scientific Instruments (J.H., P.J.), Academy of Sciences; St Anne's University Hospital (T.K., M.S., M.N., R.P., J.T., J.S.); and the Faculty of Medicine (Z.N.), Masaryk University, Brno, Czech Republic; Mayo Clinic (T.K., W.K.S., V.K.S.), Rochester, Minn; Chelsea & Westminster Hospital (D.P.F.), London; Colchester General Hospital (L.C.D.), Colchester; and the National Heart & Lung Institute (A.J.S.C.), London, UK.

Reprint requests to Josef Halámek, PhD, Institute of Scientific Instruments, AS CR, Královopolská 147, 612 64 Brno, Czech Republic. E-mail josef@isibrno.cz

Background- We postulated that the variability of the phase shift between blood pressure and heart rate fluctuation near the frequency of 0.10 Hz might be useful in assessing autonomic circulatory control.

Methods and Results- We tested this hypothesis in 4 groups of subjects: 28 young, healthy individuals; 13 elderly healthy individuals; 25 patients with coronary heart disease; and 19 patients with a planned or implanted cardioverter-defibrillator (ICD recipients). Data from 5 minutes of free breathing and at 2 different, controlled breathing frequencies (0.10 and 0.33 Hz) were used. Clear differences (P<0.001) in variability of phase were evident between the ICD recipients and all other groups. Furthermore, at a breathing frequency of 0.10 Hz, differences in baroreflex sensitivity (P<0.01) also became evident, even though these differences were not apparent at the 0.33-Hz breathing frequency.

Conclusions- The frequency of 0.10 Hz represents a useful and potentially important one for controlled breathing, at which differences in blood pressure-RR interactions become evident. These interactions, whether computed as a variability of phase to define stability of the blood pressure-heart rate interaction or defined as the baroreflex sensitivity to define the gain in heart rate response to blood pressure changes, are significantly different in patients at risk for sudden arrhythmic death. In young versus older healthy individuals, only baroreflex gain is different, with the variability of phase being similar in both groups. These measurements of short-term circulatory control might help in risk stratification for sudden cardiac death.

Key Words: baroreceptors • respiration • death, sudden *

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Diabetes Care 27:2701-2706, 2004

Glycemic Index and Dietary Fiber and the Risk of Type 2 Diabetes

Allison M. Hodge, MENVSC1 Dallas R. English, PhD Kerin O'Dea, PhD Graham G. Giles, PhD

OBJECTIVE- To examine associations between type 2 diabetes and fiber, glycemic load

(GL), dietary glycemic index (GI), and fiber-rich foods.

RESEARCH DESIGN AND METHODS- This was a prospective study of 36,787 men

and women aged 40-69 years without diabetes. For all self-reported cases of diabetes at 4-year

follow-up, confirmation of diagnosis was sought from medical practitioners. Case subjects were

those who reported diabetes at follow-up and for whom there was no evidence that they did not

have type 2 diabetes. Data were analyzed with logistic regression, adjusting for country of birth,

physical activity, family history of diabetes, alcohol and energy intake, education, 5-year weight

change, sex, and age.

RESULTS- Follow-up was completed by 31,641 (86%) participants, and 365 cases were

identified. The odds ratio (OR) for the highest quartile of white bread intake compared with the

lowest was 1.37 (95% CI 1.04 -1.81; P for trend_0.001). Intakes of carbohydrate (OR per 200

g/day 0.58, 0.36-0.95), sugars (OR per 100 g/day 0.61, 0.47- 0.79), and magnesium (OR per

500 mg/day 0.62, 0.43- 0.90) were inversely associated with incidence of diabetes, whereas

intake of starch (OR per 100 g/day 1.47, 1.06 -2.05) and dietary GI (OR per 10 units 1.32,

1.05-1.66) were positively associated with diabetes. These relationships were attenuated after

adjustment for BMI and waist-to-hip ratio.

CONCLUSIONS- Reducing dietary GI while maintaining a high carbohydrate intake may

reduce the risk of type 2 diabetes. One way to achieve this would be to substitute white bread

with low-GI breads.*

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Ann Intern Med. 2002 Apr 2;136(7):523-8.

BRIEF COMMUNICATION Change in Coronary Flow Reserve on Transthoracic Doppler Echocardiography after a Single High-Fat Meal in Young Healthy Men

Takeshi Hozumi, MD; Marc Eisenberg, MD; Kenichi Sugioka, MD; Aravind R. Kokkirala, MD; Hiroyuki Watanabe, MD; Masakazu Teragaki, MD; Junichi Yoshikawa, MD; and Shunichi Homma, MD