OBJECTIVES:We determined all-cause, cardiovascular disease (CVD), and cancer mortality in western Alaska Native people and examined agreement between death certificate information and adjudicated cause of deaths.METHODS:Data from 4 cohort studies were consolidated. Death certificates and medical records were reviewed and adjudicated according to standard criteria. We compared adjudicated CVD and cancer deaths with death certificates by calculating sensitivity, specificity, predictive values, and κ statistics.RESULTS:Men (n = 2116) and women (n = 2453), aged 18 to 95 years, were followed an average of 6.7 years. The major cause of death in men was trauma (25%), followed by CVD (19%) and cancer (13%). The major cause of death in women was CVD (24%), followed by cancer (19%) and trauma (8%). Stroke rates in both genders were higher than those of US Whites. Only 56% of deaths classified as CVD by death certificate were classified as CVD by standard criteria; discordance was higher among men (55%) than women (32%; κs = 0.4 and 0.7).CONCLUSIONS:We found lower rates for coronary heart disease death but high rates of stroke mortality. Death certificates overestimated CVD mortality; concordance between the 2 methods is better for cancer mortality. The results point to the importance of cohort studies in this population in providing data to assist in health care planning.

A long-standing association exists between elevated triglyceride levels and cardiovascular disease* (CVD).1,2 However, the extent to which triglycerides directly promote CVD or represent a biomarker of risk has been debated for 3 decades.3 To this end, 2 National Institutes of Health consensus conferences evaluated the evidentiary role of triglycerides in cardiovascular risk assessment and provided therapeutic recommendations for hypertriglyceridemic states.4,5 Since 1993, additional insights have been made vis-a-vis the atherogenicity of triglyceride-rich lipoproteins (TRLs; ie, chylomicrons and very low-density lipoproteins), genetic and metabolic regulators of triglyceride metabolism, and classification and treatment of hypertriglyceridemia. It is especially disconcerting that in the United States, mean triglyceride levels have risen since 1976, in concert with the growing epidemic of obesity, insulin resistance (IR), and type 2 diabetes mellitus (T2DM).6,7 In contrast, mean low-density lipoprotein cholesterol (LDL-C) levels have receded.7 Therefore, the purpose of this scientific statement is to update clinicians on the increasingly crucial role of triglycerides in the evaluation and management of CVD risk and highlight approaches aimed at minimizing the adverse public health–related consequences associated with hypertriglyceridemic states. This statement will complement recent American Heart Association scientific statements on childhood and adolescent obesity8 and dietary sugar intake9 by emphasizing effective lifestyle strategies designed to lower triglyceride levels and improve overall cardiometabolic health. It is not intended to serve as a specific guideline but will be of value to the Adult Treatment Panel IV (ATP IV) of the National Cholesterol Education Program, from which evidence-based guidelines will ensue. Topics to be addressed include epidemiology and CVD risk, ethnic and racial differences, metabolic determinants, genetic and family determinants, risk factor correlates, and effects related to nutrition, physical activity, and lipid medications. In the United States, the National Health and …

Background —Although cardiovascular disease (CVD) used to be rare among American Indians, Indian Health Service data suggest that CVD mortality rates vary greatly among American Indian communities and appear to be increasing. The Strong Heart Study was initiated to investigate CVD and its risk factors in American Indians in 13 communities in Arizona, Oklahoma, and South/North Dakota. Methods and Results —A total of 4549 participants (1846 men and 2703 women 45 to 74 years old) who were seen at the baseline (1989 to 1991) examination were subjected to surveillance (average 4.2 years, 1991 to 1995), and 88% of those remaining alive underwent a second examination (1993 to 1995). The medical records of all participants were exhaustively reviewed to ascertain nonfatal cardiovascular events that occurred since the baseline examination or to definitively determine cause of death. CVD morbidity and mortality rates were higher in men than in women and were similar in the 3 geographic areas. Coronary heart disease (CHD) incidence rates among American Indian men and women were almost 2-fold higher than those in the Atherosclerosis Risk in Communities Study. Significant independent predictors of CVD in women were diabetes, age, obesity (inverse), LDL cholesterol, albuminuria, triglycerides, and hypertension. In men, diabetes, age, LDL cholesterol, albuminuria, and hypertension were independent predictors of CVD. Conclusions —At present, CHD rates in American Indians exceed rates in other US populations and may more often be fatal. Unlike other ethnic groups, American Indians appear to have an increasing incidence of CHD, possibly related to the high prevalence of diabetes. In the general US population, the rising prevalence of obesity and diabetes may reverse the decline in CVD death rates. Therefore, aggressive programs to control diabetes and its risk factors are needed.

HomeCirculationVol. 100, No. 25Baseline Cholesterol Level and Magnitude of Coronary Event Reduction in Diabetic Patients With Myocardial Infarction Free AccessOtherPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessOtherPDF/EPUBBaseline Cholesterol Level and Magnitude of Coronary Event Reduction in Diabetic Patients With Myocardial Infarction Dr Colin Johnston Dr Colin JohnstonDr Colin Johnston Consultant Physician and Endocrinologist Department of Endocrinology, Hemel Hempstead General Hospital, Hemel Hempstead, Herts, UK Search for more papers by this author Originally published21 Dec 1999https://doi.org/10.1161/01.CIR.100.25.e154Circulation. 1999;100:e154To the Editor:It would be very helpful if we were able to see further analysis of the study by Goldberg et al.1 The analysis presented was for the group as a whole, which included significant variations in baseline cholesterol levels. It would be helpful if we could see an analysis similar to that performed in the LIPID study2 looking at the outcome in relation to differences in the baseline cholesterol level. Although I suspect the number of end points may affect the statistical analysis, clinicians should be able to see the raw data and draw their own conclusions. The LIPID study demonstrated statistical benefit in treating all levels of cholesterol, but there appeared to be significant differences in the numbers needed to treat, and this would have a significant impact on health economics. References 1 Goldberg RB, Mellies MJ, Sacks FM, Moyé LA, Howard BV, Howard WJ, Davis BR, Cole TG, Pfeffer MA, Braunwald E, for the CARE Investigators. Cardiovascular events and their reduction with pravastatin in diabetic and glucose-intolerant myocardial infarction survivors with average cholesterol levels: subgroup analyses in the Cholesterol And Recurrent Events (CARE) Trial. Circulation.1998; 98:2513–2519.CrossrefMedlineGoogle Scholar2 Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels: the Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) Studies Group. N Engl J Med.1998; 339:1349–1357.CrossrefMedlineGoogle ScholarcirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinsResponseSacks Frank M., MD, Pfeffer Marc A., MD, PhD, Braunwald Eugene, MD, Goldberg Ronald B., MD, Mellies Margot J., MD, Moyé Lemuel A., MD, PhD, Davis Barry R., MD, PhD, Howard Barbara V., PhD, Howard Wm. James, MD, and Cole Thomas G., PhD21121999Dr Colin Johnston is interested in whether baseline cholesterol concentrations are related to the magnitude of coronary event reduction in diabetic patients with myocardial infarction and suggests that data from the CARE population may be useful. Coronary event rates in diabetics are strongly related to serum cholesterol concentration, and therefore fewer patients may be needed to be treated to prevent an event. Although we agree that the question is important, we have not analyzed this relationship in the diabetic patients in the CARE trial because of the small size of this subgroup (586 patients). We point out that the LIPID trial also has not reported this relationship in diabetic patients. The CARE and LIPID investigators are engaged in an analysis that combines the data from these 2 similar studies of pravastatin in secondary prevention, and the total number of diabetic patients is 1444. This larger population has better potential than either individual study to give a reliable answer to the issue of risk reduction in relation to pretreatment cholesterol concentrations in diabetic patients. Previous Back to top Next FiguresReferencesRelatedDetails December 21, 1999Vol 100, Issue 25 Advertisement Article InformationMetrics Copyright © 1999 by American Heart Associationhttps://doi.org/10.1161/01.CIR.100.25.e154 Originally publishedDecember 21, 1999 PDF download Advertisement

BACKGROUND:Although diabetes is a major risk factor for coronary heart disease (CHD), little information is available on the effects of lipid lowering in diabetic patients. We determined whether lipid-lowering treatment with pravastatin prevents recurrent cardiovascular events in diabetic patients with CHD and average cholesterol levels.METHODS AND RESULTS:The Cholesterol And Recurrent Events (CARE) trial, a 5-year trial that compared the effect of pravastatin and placebo, included 586 patients (14.1%) with clinical diagnoses of diabetes. The participants with diabetes were older, more obese, and more hypertensive. The mean baseline lipid concentrations in the group with diabetes--136 mg/dL LDL cholesterol, 38 mg/dL HDL cholesterol, and 164 mg/dL triglycerides--were similar to those in the nondiabetic group. LDL cholesterol reduction by pravastatin was similar (27% and 28%) in the diabetic and nondiabetic groups, respectively. In the placebo group, the diabetic patients suffered more recurrent coronary events (CHD death, nonfatal myocardial infarction [MI], CABG, and PTCA) than did the nondiabetic patients (37% versus 25%). Pravastatin treatment reduced the absolute risk of coronary events for the diabetic and nondiabetic patients by 8.1% and 5.2% and the relative risk by 25% (P=0.05) and 23% (P<0.001), respectively. Pravastatin reduced the relative risk for revascularization procedures by 32% (P=0.04) in the diabetic patients. In the 3553 patients who were not diagnosed as diabetic, 342 had impaired fasting glucose at entry defined by the American Diabetes Association as 110 to 125 mg/dL. These nondiabetic patients with impaired fasting glucose had a higher rate of recurrent coronary events than those with normal fasting glucose (eg, 13% versus 10% for nonfatal MI). Recurrence rates tended to be lower in the pravastatin compared with placebo group (eg, -50%, P=0.05 for nonfatal MI).CONCLUSIONS:Diabetic patients and nondiabetic patients with impaired fasting glucose are at high risk of recurrent coronary events that can be substantially reduced by pravastatin treatment.

Copyright © 1998 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514 1998;98;2513-2519 Circulation and Eugene Braunwald Howard, William James Howard, Barry R. Davis, Thomas G. Cole, Marc A. Pfeffer Ronald B. Goldberg, Margot J. Mellies, Frank M. Sacks, Lemuel A. Moyé, Barbara V. Trial Levels : Subgroup Analyses in the Cholesterol And Recurrent Events (CARE) Glucose-Intolerant Myocardial Infarction Survivors With Average Cholesterol Cardiovascular Events and Their Reduction With Pravastatin in Diabetic and http://circ.ahajournals.org/cgi/content/full/98/23/2513 located on the World Wide Web at: The online version of this article, along with updated information and services, is