Showing papers by "Ralph B. D'Agostino published in 1994"
TL;DR: In addition to intrinsic cardiac causes such as valve disease and congestive heart failure, risk factors for cardiovascular disease also predispose to atrial fibrillation.
Abstract: Objective. —To determine the independent risk factors for atrial fibrillation. Design. —Cohort study. Setting. —The Framingham Heart Study. Subjects. —A total of 2090 men and 2641 women members of the original cohort, free of a history of atrial fibrillation, between the ages of 55 and 94 years. Main Outcome Measures. —Sex-specific multiple logistic regression models to identify independent risk factors for atrial fibrillation, including age, smoking, diabetes, electrocardiographic left ventricular hypertrophy, hypertension, myocardial infarction, congestive heart failure, and valve disease. Results. —During up to 38 years of follow-up, 264 men and 298 women developed atrial fibrillation. After adjusting for age and other risk factors for atrial fibrillation, men had a 1.5 times greater risk of developing atrial fibrillation than women. In the full multivariable model, the odds ratio (OR) of atrial fibrillation for each decade of advancing age was 2.1 for men and 2.2 for women (P Conclusion. —In addition to intrinsic cardiac causes such as valve disease and congestive heart failure, risk factors for cardiovascular disease also predispose to atrial fibrillation. Modification of risk factors for cardiovascular disease may have the added benefit of diminishing the incidence of atrial fibrillation. (JAMA. 1994;271:840-844)
2,962 citations
TL;DR: Among people 60 years of age or older, a low serum thyrotropin concentration is associated with a threefold higher risk that atrial fibrillation will develop in the subsequent decade.
Abstract: Background Low serum thyrotropin concentrations are a sensitive indicator of hyperthyroidism but can also occur in persons who have no clinical manifestations of the disorder. We studied whether low serum thyrotropin concentrations in clinically euthyroid older persons are a risk factor for subsequent atrial fibrillation. Methods We studied 2007 persons (814 men and 1193 women) 60 years of age or older who did not have atrial fibrillation in order to determine the frequency of this arrhythmia during a 10-year follow-up period. The subjects were classified according to their serum thyrotropin concentrations: those with low values (≤ 0.1 mU per liter; 61 subjects); those with slightly low values (>0.1 to 0.4 mU per liter; 187 subjects); those with normal values (>0.4 to 5.0 mU per liter; 1576 subjects); and those with high values (>5.0 mU per liter; 183 subjects). Results During the 10-year follow-up period, atrial fibrillation occurred in 13 persons with low initial values for serum thyrotropin, 23 with sl...
1,145 citations
TL;DR: The stroke profile can be used for evaluation of the risk of stroke and suggestion of risk factor modification to reduce risk.
Abstract: We sought to modify existing sex-specific health risk appraisal functions (profile functions) for the prediction of first stroke that better assess the effects of the use of antihypertensive medication
Health risk appraisal functions were previously developed from the Framingham Study cohort These functions were Cox proportional hazards regression models relating age, systolic blood pressure, diabetes mellitus, cigarette smoking, prior cardiovascular disease, atrial fibrillation, left ventricular hypertrophy by electrocardiogram, and the use of antihypertensive medication to the occurrence of stroke Closer examination of the data indicated that antihypertensive therapy effect is present only for systolic blood pressures between 110 and 200 mm Hg Adjustments to the regressions to better fit the observed data were developed and tested for statistical significance and goodness-of-fit of the model residuals
Modified functions more consistent with the data were developed, and, from these, tables to evaluate 10-year risk of first stroke were computed
The stroke profile can be used for evaluation of the risk of stroke and suggestion of risk factor modification to reduce risk The effect of antihypertensive therapy in the evaluation of stroke risk can now be better evaluated
676 citations
TL;DR: Results of this investigation suggest that regression of ECG features of left ventricular hypertrophy confers an improvement in risk for cardiovascular disease, whereas serial worsening imposes increased risk.
Abstract: BACKGROUNDDuring the past half-century, the ECG has been used extensively for the diagnosis of left ventricular hypertrophy. Persons with ECG evidence of left ventricular hypertrophy are at increased risk for the development of cardiovascular disease.METHODS AND RESULTSSubjects from the Framingham Heart Study with ECG evidence of left ventricular hypertrophy were eligible for this investigation if they were free of cardiovascular disease and did not have complete bundle-branch block or Wolff-Parkinson-White syndrome. Logistic regression analyses of pooled biennial examinations were used to determine risk for cardiovascular disease as a function of baseline voltage (sum of R wave in aVL plus S wave in V3) and repolarization and as a function of serial changes in these ECG features of hypertrophy. The eligible sample consisted of 274 men (mean age, 60 years) and 250 women (mean age, 64 years) who contributed 2660 person-examinations. During follow-up, there were 269 new cardiovascular events. Compared with ...
616 citations
TL;DR: The results indicate that both current and former smoking in both sexes was related to the degree of carotid atherosclerosis, and a multivariate logistic regression model showed that age, cigarette smoking, systolic blood pressure, and cholesterol were independently related to carotids.
Abstract: To investigate cardiovascular risk factors and carotid atherosclerosis, we related previously measured risk factors to carotid atherosclerosis as determined by duplex ultrasonography in the Framingham Study cohort. Risk factors measured prospectively on 1,116 cohort members, ages 66 to 93, were related to the severity of carotid atherosclerosis measured by carotid ultrasonography performed during biennial examination no. 20 (1988 to 1990). The degree of carotid atherosclerosis was expressed as a percent carotid stenosis and, for statistical analysis, subjects were divided into four groups according to percent carotid stenosis. The prevalence of significant carotid stenosis in the general population was low--7% in women and 9% in men. A multivariate logistic regression model showed that age, cigarette smoking, systolic blood pressure, and cholesterol were independently related to carotid atherosclerosis. Alcohol consumption was also significant in men, but not in women. In addition, our results indicate that both current and former smoking in both sexes was related to the degree of carotid atherosclerosis.
343 citations
TL;DR: Job strain made a modest yet statistically significant contribution beyond the effects of chronic illness and psychosocial variables and provides justification for further investigating the role of job strain as an independent risk factor for health-related quality of life.
Abstract: OBJECTIVES. Studies of the health effects of job strain have focused on morbidity and mortality as outcomes. This is the first study to examine the relationship of job strain to more comprehensive health status measures that encompass health-related quality of life. METHODS. In a national cross-sectional survey, 1319 working men and women, aged 18 through 64 years, completed a modified version of the Job Content Questionnaire that classified workers' jobs into four categories: high strain, passive, low strain, and active. Subjects also completed the Medical Outcomes Study Short-Form Health Survey and a health distress scale. Logistic regression analyses were employed that controlled for age, race/ethnicity, gender, and education. Both work and nonwork variables were included. RESULTS. Job strain was significantly associated with five of nine components of health-related quality of life: physical functioning, role functioning related to physical health, vitality, social functioning, and mental health. Job ...
166 citations
TL;DR: The findings do not support a protective effect of physical activity during adulthood for breast cancer, but suggest an increased risk among more active women.
Abstract: The authors analyzed data from the Framingham Heart Study to evaluate the association between physical activity and breast cancer risk. Physical activity was ascertained by a physician-administered questionnaire from 2,321 women at the fourth biennial examination conducted in 1954-1956. Breast cancers were identified by self-report, surveillance of admissions to Framingham Union Hospital, and review of death records; all but one were histologically confirmed. During 28 years of follow-up, 117 breast cancer cases were diagnosed among the 2,307 women with data on physical activity and reproductive history (a potential confounder). Analysis was performed using Cox proportional hazards models with age as the underlying time variable. Models were adjusted for age at physical activity assessment, menopausal status, age at first pregnancy, parity, education, occupation, and alcohol ingestion. We observed a gradient of increasing risk of breast cancer with increasing physical activity (trend p = 0.06). The relative risk for women in the highest versus lowest activity quartile was 1.6 (95% confidence interval 0.9-3.0; p = 0.13). Although both moderate-to-heavy leisure and occupational activities were associated with an increased risk, the association was marginally significant only for leisure activity (p = 0.06). Our findings do not support a protective effect of physical activity during adulthood for breast cancer, but suggest an increased risk among more active women.
136 citations
TL;DR: It is concluded that women who were more active lived longer; this effect was not the result of decreased cardiovascular disease.
117 citations
TL;DR: It is concluded that women aged 75 years or older who are more active live longer, although this benefit may be attenuated in those who are extremely active.
99 citations
Journal Article•
TL;DR: The type II diabetes PORT study will examine the effectiveness of preventive care and established disease treatment in relation to eye, cardiovascular, and extremity disease, measuring and relating use of health-care services to patient outcomes.
Abstract: Randomized controlled trials (RCTs), such as the Diabetes Control and Complications Trial (DCCT), usually evaluate the efficacy of a single treatment strategy. The DCCT, for example, evaluates intensive diabetes management aimed at achieving glucose levels as close to normal as possible to modify specific pathophysiological outcomes--specifically, the development or worsening of microvascular disease. In contrast, longitudinal observational studies, such as the type II diabetes Patient Outcome Research Team (PORT) study, address medical effectiveness; that is, how well prevailing treatments work in clinical practice settings. The PORT relies heavily on patient-reported measures of general and diabetes-specific health status, in addition to using complications as major study outcomes. In the type II diabetes PORT, 4,000 patients with type II diabetes and a wide range of socioeconomic, demographic, and disease characteristics, from three widely dispersed geographic settings and varying systems of care, are being followed for a 2.5-year period. Data are collected from periodic self-administered patient questionnaires and from administrative data bases. In the PORT study, nonmutable confounders, such as case-mix, and potentially mutable features, such as patients' preferences for treatment, health habits, regimen adherence, family support, and physician's interpersonal style, are carefully measured. The PORT study will examine the effectiveness of preventive care and established disease treatment in relation to eye, cardiovascular, and extremity disease, measuring and relating use of health-care services to patient outcomes. The results have the potential for maximizing quality of care and minimizing use of services in type II diabetes by matching physician-level profiles of patient outcomes with medical-care-process data and making this information accessible to practicing physicians.
69 citations
TL;DR: Suggested revisions to the American Dental Association's 1985 guidelines for acceptance of anti-gingivitis chemotherapeutic agents articulate certain aspects of study design which were implicit in the 1985 guidelines, clarify language on cross-over designs and independence of studies, and recommend use of a United States population in at least one trial supporting a product.
Abstract: This paper presents suggested revisions to the American Dental Association's 1985 guidelines for acceptance of anti-gingivitis chemotherapeutic agents. The areas of study design, choice and quality control of clinical gingivitis measurements, statistical analysis, and minimum strength of effect, are addressed. The revisions articulate certain aspects of study design which were implicit in the 1985 guidelines, clarify language on cross-over designs and independence of studies, and recommend use of a United States population in at least one trial supporting a product. Separate recording and analysis of a product's effect on gingival bleeding is proposed, and quality control of clinical measurements receives enhanced emphasis. Modestly elaborated statistical reporting guidelines and strengthened approval criteria, based on size of estimated effect as well as statistical significance, are advocated.
TL;DR: Excess pulse blood pressure predicted thrombolysis-related intracranial hemorrhage better than other forms of pretreatment blood pressure, perhaps better describing the pathophysiology of intrac Cranium hemorrhage, including the effect of age.
Abstract: BACKGROUNDIn selecting patients with acute myocardial infarction for thrombolytic therapy, it is important to identify patients who are at high risk for intracranial hemorrhage, for whom thrombolytic therapy is ill advised. We hypothesized that presenting pulse blood pressure, representing the "hammer" effect on cerebral vessels and the effects of age on arterial compliance, might predict thrombolysis-related intracranial hemorrhage better than systolic, diastolic, or mean arterial blood pressures.METHODS AND RESULTSOf 3483 Thrombolytic Predictive Instrument (TPI) Project subjects receiving thrombolytic therapy for acute infarction, we identified and obtained detailed clinical data on the 19 with treatment-related intracranial hemorrhages confirmed by computed tomography and on 175 matched controls. Systolic, diastolic, mean arterial, and pulse blood pressures were each significantly related to the occurrence of intracranial hemorrhage, with pulse pressure most highly related. The mean pulse pressure in p...
TL;DR: ECG-LVH was not a benign ECG finding among the patients who had presented with symptoms suggesting an acute cardiac ischemic syndrome, and routine use of thrombolytic therapy for patients who have ECG- LVH does not seem warranted.
Abstract: Objective: To understand the diagnostic and short-term prognostic significance of electrocardiographic left ventricular hypertrophy (ECG-LVH) for patients who present to the emergency department with symptoms suggesting acute cardiac ischemia, defined as new or unstable angina pectoris or acute myocardial infarction.
TL;DR: This congestive heart failure mortality TIPI shows potential for risk-adjusted studies of hospitals, mortality for multi-hospital groups, hospital-to-hospital comparisons, and potentially for within-hospital assessment and if further validated, potentially also for real-time clinical use.
Abstract: The purpose of this study was to develop a "time-insensitive" predictive instrument (TIPI) for acute hospital mortality due to congestive heart failure. In Phase 1, based on prospectively collected data on 401 congestive heart failure patients among 5,773 study patients who presented to six New England hospitals over a 2-year period whose chief complaints were chest pain, shortness of breath, or other cardiac symptoms, a multivariable logistic regression was used to develop the TIPI for acute mortality. Discrimination between patients who lived and those who died was reflected by receiver-operating characteristic (ROC) curve area of 0.90. Predicted mortality was found to not vary significantly from actual mortality rates across deciles of predicted probabilities from 0% to 100%. In Phase 2, the six hospitals' actual mortality rates for their congestive heart failure patients were compared to their respective rates predicted by the TIPI. Actual hospital mortality rates ranged from 3.6% to 11.3%, with no hospital having a statistically significantly higher rate. Predicted mortality rates ranged from 4% to 9%, with one hospital having a significantly lower predicted rate (P = .01), and one hospital having a borderline significantly higher predicted rate (P = .07). Individual hospitals' differences between actual and predicted mortality ranged from -3.8% to +4.7% (all NS). When grouped by hospital type, respectively for urban teaching, smaller city teaching, and rural non-teaching hospitals, the actual mortality rates were 5.1%, 10.5%, and 5.4%, (NS). The predicted mortality rates were 8.3%, 6.1%, and 5.4%, respectively, with the rate for urban major teaching centers being sig
TL;DR: In this paper, intraindividual variability in serum TC in 2912 men and women having TC measured at each of biennial examinations 2 through 7 of the FHS was examined, and age-adjusted analyses showed positive associations with all-cause mortality over a 24-year period in men and a positive relation to cardiovascular and coronary incidence and mortality in both sexes.
TL;DR: The guidelines suggested here are meant to form the basis of an evolving document rather than a static standard, and it is suggested that they be reviewed frequently in the light of improvement in the technology available for periodontal research, and the emergence of products representing new approaches toperiodontal therapy.
Abstract: Guidelines are suggested for determining efficacy of products to supplement scaling and root planing in professional, non-surgical treatment of adult periodontitis. They result from an extended process including a conference on clinical trials in gingivitis and periodontitis, a subsequent workshop, and commentary from industrial, academic, professional and governmental members of the periodontal research community on two drafts. Recommendations are made in the broad areas of basic study design, subject and periodontal site selection, clinical management, choice of outcome variables, statistical summarization and analysis, and criteria for acceptance. Prominent dissenting views, with justifications for positions taken here, are also provided. Groundwork is laid for possible future guidelines addressing products for primary prevention or over-the-counter uses, or for determining superiority or equivalence of competing products. However, issues are identified which require further exploration before responsible and widely acceptable recommendations can be made in these areas. The guidelines suggested here are meant to form the basis of an evolving document rather than a static standard. It is suggested that they be reviewed frequently in the light of improvement in the technology available for periodontal research, and the emergence of products representing new approaches to periodontal therapy.
Journal Article•
TL;DR: It is concluded that the anticaries efficacy of SMFP dentifrices rises with increasing fluoride, and that the anti-dementia efficacy of a 2000 ppm NaF dentifrice is superior to that of a2000 ppm F SMFP Dentifrice.
TL;DR: The results indicate that several of the new groups in nursing view nursing less as a “calling,” finding the field appealing for practical socioeconomic reasons and accessibility.
Abstract: Chronic shortages of registered nurses (RNs) have stimulated interest in locating non-traditional sources of RNs. A statewide survey of 2,315 newly graduated RNs compared three non-traditional groups in nursing with their traditional counterparts, identifying differences that have implications for successful recruitment and retention. Second career nurses, former LPNs and minorities comprised 41.9% of the population. Compared to the traditional groups, more second career nurses, former LPNs and some minority groups were older, married and had children. Second career vs. first career nurses placed less emphasis on selecting schools at the highest levels of academic quality, holding out for the most lucrative jobs or working with the most "interesting" patients (i.e., the acutely ill). Former LPNs, compared to other RNs, placed greater value on easy access to schools and jobs. Compared to whites, minority RNs were more inclined to value nursing's socioeconomic rewards. However, compared to non-Asian minorities in nursing, Asian RNs had higher expectations for professional advancement and were less altruistic. Our results indicate that several of the new groups view nursing less as a "calling," finding the field appealing for practical socioeconomic reasons and accessibility.
Journal Article•
TL;DR: Mentadent, a fluoride toothpaste with baking soda and peroxide, was shown to reduce enamel demineralization and to provide protection comparable to a clinically tested dentifrice (Crest Regular).
Abstract: Ongoing efforts within the oral care industry to improve dentifrices by the addition of anti-tartar compounds, bicarbonate and other agents, have necessitated the continuing evaluation of new products in order to assure their anti-caries effectiveness. However, clinical evaluation of new products is time consuming, prohibitively expensive and ethically questionable. Recently, a number of intraoral models have been developed that appear to be well-suited to evaluate new products. In the present study, an intraoral system was used that monitors short-term demineralization of surface enamel. Subjects wore appliances that contained Streptococcus mutans-coated blocks of bovine enamel and rinsed first with 15 ml of a 20% slurry of dentifrice and, after 30 minutes, with a 10% sucrose solution. Iodide penetrability (Ip) was determined before and after each intraoral exposure, and the difference, or delta Ip, was taken as the measure of demineralization. The model system responded linearly to increasing concentrations of fluoride in a series of standard dentifrice preparations. Mentadent, a fluoride toothpaste with baking soda and peroxide, was shown to reduce enamel demineralization and to provide protection comparable to a clinically tested dentifrice (Crest Regular). These results established the validity of the delta Ip method, and demonstrated the efficacy of Mentadent according to the criteria established at the ADA Consensus Conference on Intraoral Models in 1990.
TL;DR: Using the cutoff for hypertension traditionally used by the Framingham Study (160/95 mm Hg), this study avoided the milder elevations of blood pressure that may have occurred and found evidence that trait anxiety plays a role in white coat hypertension.
Abstract: In Reply. —Drs Gross and Mann discuss the possibility of white coat hypertension confounding the results of our study, particularly among anxious individuals. The concept of white coat hypertension was not established until the mid 1980s, so it is possible that some individuals in this study who were given medication by their private physicians for hypertension had white coat hypertension. In addition, all blood pressures recorded for the Framingham Study were performed by the examining physician; therefore, it is possible that elevated clinic blood pressures were also attributable to white coat hypertension. By using the cutoff for hypertension traditionally used by the Framingham Study (160/95 mm Hg), we avoided the milder elevations of blood pressure that may have occurred. However, previous studies have not found evidence that trait anxiety plays a role in white coat hypertension. 1,2 In addition, white coat hypertension is more prevalent in women, 3 and no