Christ Aravanis

The Seven Countries Study : 2,289 deaths in 15 years

Among 11,579 men ages 40-59 without evidence of cardiovascular disease, 2,289 died in 15 years, 618 from coronary heart disease. The 15 cohorts in seven countries (four regions) differed in all-causes death rate, mainly reflecting great differences in coronary mortality. Among characteristics of entry, only mean blood pressure helped to explain cohort differences in all-causes death rate. Three-quarters of the variance in coronary death rate was accounted for by differences in mean serum cholesterol and blood pressure of the cohorts. The mortality risk for individuals was examined in each of the regions. For coronary death, age, serum cholesterol, blood pressure, and smoking were highly significant in all regions except Japan, where coronary deaths were too few for evaluation. Relative weight was not significant anywhere. Physical activity was significant only in southern Europe, where differences are associated with socioeconomic status. For all-causes death, age and blood pressure were highly significant risk factors in all regions as was smoking habit, except in Japan. Relative body weight tended to be a negative risk factor everywhere, significantly so in southern Europe. Expectations for coronary death from the experience in the United States and northern Europe greatly exceeded observed deaths in southern Europe for men of their age, serum cholesterol, blood pressure, smoking habits, physical activity, and relative weight. The reverse, prediction of coronary deaths in America and in northern Europe from the southern European experience, greatly underestimated the deaths observed. Similar cross-predictions between the United States and northern Europe were good for all-causes deaths, excellent for coronary deaths. Analysis of time trends in relationships of mortality to entry characteristics showed continued importance of age, blood pressure, and smoking and a tendency for the importance of cholesterol to fall in the last 5 years of follow-up.

Coronary heart disease: overweight and obesity as risk factors.

Abstract The relationship of relative weight and of skinfold thickness to the 5-year incidence (632 cases) of coronary heart disease was examined in men aged 40 through 59 years at entry to the stu...

Twenty-five-year prediction of stroke deaths in the seven countries study: the role of blood pressure and its changes.

BACKGROUND AND PURPOSE This report explores the prediction of long-term stroke mortality in cohorts of the Seven Countries Study. METHODS Sixteen cohorts of men aged 40 to 59 years at entry were examined at years 0, 5, and 10, with mortality follow-up through 25 years. RESULTS Stroke death rates in 25 years were high in rural Serbia, Croatia, and Japan; intermediate in Italy, Greece, and urban Serbia; and low in Finland, the Netherlands, and the United States. Age and blood pressure were powerful predictors of 25-year stroke mortality in almost all cohorts and countries. Proportional hazards regression coefficients were .0232 increase in stroke death hazard per millimeter of mercury (t=14.60) for systolic blood pressure and .0409 (t=13.41) for diastolic blood pressure. Moderate blood pressure increases from low usual levels were associated with lower stroke mortality rates in years 10 to 25. Increases of blood pressure starting from high usual levels were associated with increased rates of stroke mortality. Systolic blood pressure was associated with stroke mortality at given levels of diastolic pressure, but diastolic blood pressure was not predictive of stroke mortality at given levels of systolic blood pressure. CONCLUSIONS Associations of systolic and diastolic blood pressure with stroke mortality were similar in cultures with different stroke mortality rates. Increases in blood pressure were associated with subsequent excess stroke mortality only in those who started from high usual levels; this study finds lower stroke risk in those men whose blood pressure increased moderately from low usual levels. Diastolic blood pressure is not independently associated with stroke risk in these populations.

IX. The Greek Islands of Crete and Corfu

T HE IMMEDIATE forerunners to the present International Cooperative Study on Cardiovascular Epidemiology were two full-dress trials in September-November, 1957: one at Nicotera, a farming village close to the toe of the Italian boot, the other in a series of 11 villages in the north central part of the island of Crete. Those trials tested the proposed plans for the long-range study-the protocol, the goal of enrolling in the cohorts substantially all men of designated age in geographically defined areas, the use of international teams of examiners, chemical analyses, as well as analyses of the ECG, examination findings, etc., and statistical work to be done at the coordination center at Minnesota. Those trials fulfilled all requirements, and the experience on the island of Crete was notable in the favorable response of more than 95% of the men invited to the examinations, the willingness of the wives to participate in detailed dietary studies, the confirmation of expectations about the dominant place of olive oil in the diet, and the remarkable rarity of coronary heart disease (CHD). Financial restrictions limited the details of

Serum lipids, apoproteins and nutrient intake in rural Cretan boys consuming high-olive-oil diets.

A high intake of olive oil has produced high levels of high-density and low levels of low-density lipoprotein cholesterol in short-term dietary trials. To investigate long-term effects of olive oil we have studied the diet and serum lipids of boys in Crete, where a high olive oil consumption is the norm. Seventy-six healthy rural Cretan boys aged 7-9 years were studied. The diet was assessed by a 2-day dietary recall. Blood was collected according to a standardized protocol and sera were analyzed in a rigidly standardized laboratory. The mean daily intake of energy was 11.0 MJ (2629 kcal). The intake of fat (45.0% of energy) and oleic acid (27.2% of energy) was high, and that of saturated fat low (10.0% of energy), reflecting a high consumption of olive oil. The high consumption of olive oil was confirmed by a high proportion of oleic-acid (27.1%) in serum cholesteryl fatty acids. Mean concentration of serum total cholesterol was 4.42 mmol l-1 (171 mg dl-1), of HDL-cholesterol 1.40 mmol l-1 (54 mg dl-1), of serum triglycerides 0.59 mmol l-1 (52 mg dl-1), of apo-AI 1210 mg l-1 and of LDL apo-B 798 mg l-1. The body mass index of the Cretan boys (18.2 kg m-2) was on average 2 kg m-2 higher than that of boys from other countries. Contrary to our expectation, the Cretan boys did not show a more favourable serum lipoprotein pattern than boys from more westernized countries studied previously using the same protocol. Our hypothesis that a typical, olive-oil-rich Cretan diet causes a relatively high HDL- to total cholesterol ratio is not supported by the present findings.

Silent mitral insufficiency

Abstract Four cases of marked mitral insufficiency without systolic murmur are presented. Absence of the systolic murmur was proved not only by auscultation, but also by phonocardiography. In all cases the diagnosis of mitral insufficiency was missed clinically and mitral stenosis was diagnosed. The patients were incapacitated because of exertional dyspnea and nocturnal paroxysmal dyspnea. Left ventricular enlargement was not evidenced either clinically or by x-ray examination. The left atrium was slightly enlarged in 2 of the patients but without a systolic expansion. Right ventricular enlargement was found in all patients. The electrocardiogram proved to be, retrospectively, the most valuable aid in detecting left ventricular hypertrophy in 3 of the 4 patients. Right heart catheterization did not help significantly in verifying or excluding the presence of mitral regurgitation. During the operation a marked degree of mitral regurgitation was found and mitral stenosis was slight to moderate in degree. It is evident that mitral insufficiency may exist without a systolic murmur. In these cases, auscultation and phonocardiography are unreliable diagnostic means, so that other criteria should be taken into consideration.

WOLFF-PARKINSON-WHITE SYNDROME. RIGHT VENTRICULAR PRECONTRACTING AREA PROVED BY CARDIAC CATHETERIZATION.

Abstract A case of Wolff-Parkinson-White syndrome studied by left and right heart catheterization and phonocardiography is presented. The electrocardiograms in a five year follow-up showed remarkable changes which are discussed. The phonocardiogram disclosed a double wave before the first heart sound but no splitting of the heart sounds. The right ventricular pressure tracing confirmed the existence of a precontraction area in the right ventricle. Left and right heart catheterization proved that there was no delay in the effective contraction of both ventricles.

Diagnostic Significance of Atrial Fibrillatory Waves

* From the Department of Cardiology of the University of Athens, Medical School, at the Hippocrates Hospital, Athens, Greece. Although Hewlett and Wilson’ in 1915 presented a case of atrial fibrillation with tall f waves, the diagnostic significance of the pattern of atrial f waves did not attract interest until later. Cookson,2 after the analysis of a small number of EKG records, concluded that in rheumatic heart disease the amplitude of the f waves was of &dquo;medium size&dquo; in the majority of cases, in contrast to arteriosclerotic heart disease, in which these waves were of &dquo;small size.&dquo; Thirty years later other investigators3, 4 verified the findings of Cookson and stated

Opening snap in relative tricuspid stenosis: Report of two cases of atrial septal defect∗

Abstract The auscultatory and phonocardiographic findings in 2 cases of atrial septal defect are presented. The diagnosis of the disease was confirmed by cardiac catheterization. A large left to right shunt was present in both cases. In addition to the usual auscultatory and phonocardiographic findings of atrial septal defect, an opening snap of high frequency was clearly audible and registered at the xiphoid, the left lower sternal border and to the right of the sternum. This opening snap is attributed to the sudden billowing of the tricuspid leaflets caused by increased flow across the valve. At the same time a diastolic rumble was present in the same area, and the first sound was loud and split. The presence of an opening snap, in addition to the other auscultatory and graphic findings, can be a source of diagnostic error in cases of atrial septal defect.

Pulseless disease: Report of a case

Abstract A case of pulseless disease is presented. This is the second case from Greece. The essential findings were complete absence of the pulse in the arms and both carotid arteries. Typical subjective symptoms and objective findings were present because of the diminished circulation in the upper extremities and the central nervous system. Since the number of reported cases is still limited, publications such as ours will focus more attention on this syndrome, with the probability that more cases will be diagnosed.