High density lipoprotein as a protective factor against coronary heart disease: The Framingham study

Health and Well-Being in the Workplace: A Review and Synthesis of the Literature

Prospective data at Framingham and elsewhere have shown conclusively that risk of coronary heart disease in persons younger than age 50 is strikingly related to the serum total cholesterol level. Within so-called normal limits risk has been found to mount over a 5-fold range. The impact has been found to be augmented by other risk factors. The contribution of the serum total cholesterol to risk has also been found to be determined by its partition in the various lipoprotein fractions. A relatively large amount of cholesterol in the low-density lipoprotein fraction is atherogenic whereas that in the high-density fraction appears protective. The independent contribution of very-low-density lipoprotein and its triglyceride or cholesterol content has on the other hand not been established. The previous position that virtually all of the lipid information pertaining to coranary heart disease resided in the serum total cholesterol must be accordingly modified. (authors)

Cholesterol in the prediction of atherosclerotic disease. New perspectives based on the Framingham study.

Felton & Cole (1963) estimate that all cardiovascular diseases accounted for 12 per cent of the time lost by the ‘working population’ in the US, for a total economic loss of about $4 billion in a single year. A report (1969) by the Department of Health and Social Security in the UK shows, as Aldridge (1970) indicates, that the sum of incapacity for men suffering from mental, psychoneurotic and personality disorders, nervousness, debility and migraine headache accounted for 22·8 million work days lost in 1968 alone (second only to bronchitis in the league table of illness and lost working days). Coronary heart disease and mental ill health together, therefore, represent a serious cost for industry both in human and financial terms.

Occupational sources of stress: a review of the literature relating to coronary heart disease and mental ill health

Of 708 myocardial infarctions among 5127 participants in the Framingham Study, more than 25 per cent were discovered only through the appearance of new diagnostic evidence during routine biennial electrocardiographic examinations. Of these unrecognized infarctions almost half were "silent," and the others caused atypical symptoms. The proportion of all infarcts that were unrecognized was higher in women and in older men. Such infarcts were uncommon in persons with angina. Unrecognized infarctions were as likely as recognized ones to cause death, heart failure, or strokes. Recurrent infarctions were more common in women with recognized than with unrecognized infarcts, but this difference was not present in men. Recurrent infarctions were more likely to be recognized than were first infarctions. We conclude that unrecognized infarctions are common and have as serious a prognosis as recognized infarctions.

Incidence and prognosis of unrecognized myocardial infarction. An update on the Framingham study.

This study was designed to (1) compare "predictive" abilities of different parameters and their interrelationships in the future incidence of coronary heart disease (CHD) and (2) define the profile of coronary-prone males through retrospective analysis of prospectively obtained data. Comprehensive studies of overt behavior pattern, blood lipids and coagulation, body measurements, socioeconomic factors, individual habits, and cardiovascular status were obtained annually since 1960 in 3,524 men, aged 39 to 59 years. Manifest CHD was found in 113 of 3,411 "well" men, but this was unknown to the investigators at the time of the study. The men with CHD exhibited higher serum beta/alpha lipoprotein ratios and 80 of them had been adjudged in "blind" assessments to exhibit an overt behavior pattern (type A) previously found associated with occurrence of CHD in middle-aged men.

https://jamanetwork.com/journals/jama/articlepdf/1163684/jama_189_1_004.pdf

A Predictive Study of Coronary Heart Disease: The Western Collaborative Group Study

The relationship of behavior pattern A to the state of the coronary vasculature. A study of fifty-one autopsy subjects.

The occurrence of silent and other clinically unrecognized myocardial infarction prior to the study was observed in 42 men and in 31 new cases of infarction during a four and a half year follow-up of 3,182 men, aged 39 to 59 years, participating in an epidemiologic study of coronary heart disease. Among subjects aged 39 to 49 years, a statistically significantly higher frequency of unrecognized infarction occurred in those with a parental history of coronary heart disease, higher annual income, fasting serum triglycerides exceeding 150 mg./100 ml. and in those who exhibited the Type A behavior pattern, compared with subjects without such attributes. A higher frequency also was observed in the younger subjects who were cigarette smokers compared with former smokers and nonsmokers of cigarettes and in those with elevated blood pressure compared to those with normal pressure, but these differences were not statistically significant. A significantly higher incidence of unrecognized infarction also was observed in all subjects with elevated serum beta/alpha lipoprotein ratios compared to those with lower ratios. This appears to be particularly striking since there were no significant differences in the incidence of such infarction among subjects with elevated serum cholesterol levels compared to those with low levels. Most cases of unrecognized infarction were associated with the Type A behavior pattern, and this was independent of the blood pressure, serum lipid or lipoprotein levels, cigarette smoking, parental history or any of the other factors under study.

Clinically unrecognized myocardial infarction in the Western Collaborative Group Study.

Prospectively gathered data were compared in subjects with recurring and nonrecurring myocardial infarction and in subjects with fatal and nonfatal infarction observed during a four and a half year period of follow-up in an epidemiologic study of clinical coronary heart disease in employed men. The younger subjects with recurring infarction exhibited higher frequency of elevated serum cholesterol levels and the Type A behavior pattern compared to men with nonrecurring infarction. The subjects of all ages with recurring infarction more often were heavier cigarette smokers and more often exhibited arcus senilis and elevated serum beta/alpha lipoprotein ratios. However, only the finding of a higher frequency of diastolic hypertension in the older subjects with recurring infarction was statistically significant. The Type A behavior pattern was found in significantly higher frequency both in subjects with recurring and nonrecurring infarction compared with those without clinical coronary heart disease. Subjects with fatal infarction exhibited significantly higher frequency of elevated serum cholesterol and less often a history of regular exercise habits compared with subjects with nonfatal infarction. Other trends characterizing the fatal compared with nonfatal cases (but which were not statistically significant) included a higher frequency of cigarette smoking, elevated serum beta/alpha lipoprotein ratios and the Type A behavior pattern. The latter was observed both in subjects with fatal and those with nonfatal infarction in significantly higher frequency than in men without clinical disease.

Recurring and fatal myocardial infarction in the Western Collaborative Group Study.

The occurrence of new coronary heart disease (CHD) in the presence of below average serum levels of lipids and lipoproteins was studied during a 4 1/2-year period of observation of 2,998 normotensive men, aged 39 to 59 years at intake into a prospective, epidemiological investigation. It was found from this study that the normotensive, middle-aged man with the fully developed type B behavior pattern was essentially immune to the development of clinical CHD if he exhibited a serum cholesterol level less than 226 mg/100 ml, a serum triglyceride level less than 126 mg/100 ml, or a serum β-/α-lipoprotein ratio less than 2.01, singly or in combination.

Robert Kositchek

Papers

A Predictive Study of Coronary Heart Disease: The Western Collaborative Group Study

The relationship of behavior pattern A to the state of the coronary vasculature. A study of fifty-one autopsy subjects.

Clinically unrecognized myocardial infarction in the Western Collaborative Group Study.

Recurring and fatal myocardial infarction in the Western Collaborative Group Study.

The Prediction of Immunity to Coronary Heart Disease