Harvey W. Gruchow

Postmenopausal use of estrogen and occlusion of coronary arteries

The degree of coronary artery occlusion was compared between users and nonusers of postmenopausal estrogen among 933 female patients undergoing angiography between the ages 50 and 75 years in the Milwaukee Cardiovascular Data Registry. Users (n = 154) had less occlusion than nonusers (n = 779), and a significant increase in occlusion scores with age was evident for nonusers (p less than 0.001) but not for users (p = 0.50). The age-adjusted odds ratios for use of postmenopausal estrogen among women with moderate and severe levels of occlusion of the coronary arteries were 0.59 (95% confidence interval, 0.48 to 0.73) and 0.37 (95% confidence interval, 0.29 to 0.46), respectively, which indicated a statistically significant, apparent protective effect of postmenopausal estrogen on coronary occlusion. This effect was independent of the type of menopause or other risk factors but not independent of high-density lipoprotein-cholesterol levels. Higher high-density lipoprotein-cholesterol levels among users may indicate a biologic mechanism by which postmenopausal estrogen use lowers the risk of coronary occlusion.

Body fat distribution and male/female differences in lipids and lipoproteins.

The role of body fat distribution, as assessed by the ratio of waist-to-hip circumferences (WHR), in statistically explaining differences in levels of lipoproteins between men and women was studied using data collected in 1985-1986 from employed adults (mean age, 40 years). As compared with the 415 women, the 709 men had higher mean levels of triglycerides (+38 mg/dl) and apolipoprotein B (+11 mg/dl) as well as lower mean levels of high density lipoprotein (HDL) cholesterol (-15 mg/dl) and apolipoprotein A-I (-19 mg/dl). Additionally, men were more overweight, consumed more alcohol, and exercised more frequently than women but were less likely to smoke cigarettes. Controlling for these characteristics, however, did not alter the differences in lipoprotein levels between men and women. In contrast, adjustment for WHR (which was greater among men) reduced the sex differences in levels of apolipoprotein B (by 98%), triglycerides (by 94%), HDL cholesterol (by 33%), and apolipoprotein A-I (by 21%). Similar results were obtained using analysis of covariance, stratification, or matching; at comparable levels of WHR, differences in lipid and lipoprotein levels between men and women were greatly reduced. Although these results are based on cross-sectional analyses of employed adults and need to be replicated in other populations, the findings emphasize the relative importance of body fat distribution. Whereas generalized obesity and body fat distribution are associated with lipid levels, fat distribution (or a characteristic influencing fat patterning) can be an important determinant of sex differences in levels of triglycerides, HDL cholesterol, and apolipoproteins B and A-I.

Body fat distribution, plasma lipids, and lipoproteins.

The relation of body fat distribution as measured by the ratio of waist to hip circumferences (WHR) to plasma levels of lipids and lipoproteins was studied In 713 men and 520 women who were employed by two Milwaukee companies. Quetelet Index (kg/m2), waist girth, hip girth, and WHR were each positively related to levels of total cholesterol, trlglycerldes, apollpoproteln B, and the ratio of total to high density llpoproteln (HDL) cholesterol. In addition, the anthropometrlc measures were Inversely associated with levels of HDL cholesterol. (Controlling for age, alcohol intake, exercise level, current smoking status, and oral contraceptive use only slightly reduced the strength of the correlations.) In addition, WHR and Quetelet Index were Independently related to llpld and llpoproteln levels, and the magnitudes of the associations were roughly equivalent For example, the mean (covarlate-adjusted) trlglycerlde level among men In the upper tortile of the Quetelet Index was 37 mg/dl higher than for men in the lower tertlle of the Quetelet Index; the corresponding difference according to WHR tertlles (upper to lower) was 39 mg/dl (p<0.01 for both effects). These findings Indicate that In healthy men and women a less favorable lipid and llpoproteln profile Is associated with elevated levels of both Quetelet Index and WHR.

Effects of drinking patterns on the relationship between alcohol and coronary occlusion

Previous reports have described an inverse relationship between alcohol consumption and the prevalence of myocardial infarction or the extent of coronary artery occlusion. The study reported here explored the relationship between patterns of alcohol intake and coronary occlusion in 526 patients who have had coronary arteriography. Patients were characterized as regular drinkers, occasional drinkers and non-drinkers. Regular drinkers were further characterized as drinking relatively consistent amounts or variable amounts. The inverse correlation between amounts of alcohol consumed and coronary occlusion found in previous studies was reaffirmed. It was also observed that the pattern of alcohol intake was related to the degree of occlusion. Higher levels of occlusion were found among non-drinkers, occasional drinkers, and regular drinkers with patterns of variable intake, while significantly lower levels of occlusion were observed for regular drinkers who drank relatively consistent amounts (P = 0.014). Furthermore, while occlusion scores were inversely correlated with amounts consumed by regular drinkers with consistent intake (P = 0.019), drinkers with variable drinking patterns had higher occlusion scores regardless of amounts consumed. Analyses of serum lipids according to drinking patterns showed a significant association between the total/HDL cholesterol ratio and drinking patterns. These findings suggest that whatever attenuating effect alcohol consumption might exert on coronary occlusion, it appears to be reversed by a variable or sporadic pattern of alcohol intake.

Resuscitation time in ventricular fibrillation — a prognostic indicator

Length of resuscitation in prehospital ventricular fibrillation patients was studied to define its relationship to survival. Five hundred sixty-five patients presenting with the initial rhythm of ventricular fibrillation to the Milwaukee County Paramedic System between January 1978 and April 1982 were resuscitated successfully. Pediatric patients and patients with trauma, poisoning, and drowning were excluded. Of the 565 resuscitated patients, 262 (46%) were discharged alive and 303 (54%) died during hospitalization. For all 565 patients the resuscitation time and times from arrival of paramedics until the first sustained pulse were plotted against survival to define a curve. The curve demonstrated rapidly declining survival rates for resuscitation time up to 20 minutes; thereafter, survival declined more gradually with respect to resuscitation time. The mean resuscitation time for those eventually discharged alive was 12.6 minutes, which was statistically shorter (P less than .0001) than the mean resuscitation time of 23.9 minutes for those who eventually died. The overall survival curve of witnessed arrest patients was not statistically different from that of unwitnessed patients. The survival curve of those patients receiving bystander cardiopulmonary resuscitation (CPR) was similar to the curve of those who received no CPR. We conclude that resuscitation time is a heretofore undefined significant predictor of survival of resuscitated prehospital ventricular fibrillation patients.

Decision making in prehospital sudden cardiac arrest

Many studies of prehospital resuscitation report on selected populations. We examined a series of 445 unselected nontraumatic cardiac arrests. Emergency cardiac care (ECC) was not initiated in 126 (28%). ECC was begun in 319 (78%), but was terminated in 132 (33%). Ninety-four (21%) were admitted to the hospital with palpable pulses and organized rhythm (successful resuscitation/save rate for patients presenting in ventricular fibrillation was 50%/25%. Multivariate regression analysis was used to identify the relative importance of significant variables in predicting survival, and the analysis identified the presence of ventricular fibrillation, short paramedic response times, and short paramedic treatment times.

Randomized study of epinephrine versus methoxamine in prehospital ventricular fibrillation

Experimental data suggest that a pure alpha-agonist, such as methoxamine, may improve the outcome of patients in ventricular fibrillation. A double-blind, randomized, prospective study was conducted in a paramedic system comparing the use of methoxamine with epinephrine in enhancing conversion of ventricular fibrillation while otherwise following American Heart Association protocols. One hundred two patients in ventricular fibrillation not responding to initial defibrillations with a pulsatile rhythm were randomized into one of two groups, each containing 51 patients. Equipressor doses of epinephrine (0.5 mg) and methoxamine (5 mg) were given intravenously and repeated according to American Heart Association guidelines. The mean age, sex ratio, and mean paramedic response times were comparable for the two groups. The mean time at scene until conversion was 22 +/- 10 minutes for methoxamine and 17 +/- 7 minutes for epinephrine (P = NS). The methoxamine group received 3.1 +/- 1.4 doses as compared with 2.8 +/- 1.3 doses for the epinephrine group (P = NS). Conversion rate, defined as the percentage of patients who developed a pulse during resuscitation, was 27.5% for the methoxamine group and 49.0% for the epinephrine group (P less than or equal to .03). Successful resuscitation, defined as the conveyance of a patient to an emergency department with a pulse and rhythm, was 17.7% for the methoxamine group and 39.2% for the epinephrine group (P less than or equal to .02). Save rate, defined as the percentage of patients discharged alive after hospitalization, was 7.8% for the methoxamine group and 19.6% for the epinephrine group (P less than or equal to .07).(ABSTRACT TRUNCATED AT 250 WORDS)

Primary care providers need a variety of nutrition and wellness patient education materials

OBJECTIVE To assess and document the need for nutrition and wellness patient education materials. DESIGN The results of open-ended interviews and focus groups were used to develop a mail-type survey. The 46-item survey addressed barriers to using nutrition and wellness education materials as well as format, education/reading level, foreign languages, and topics needed. North Carolina Cooperative Extension Service (NCCES) family and consumer education agents distributed surveys to family and general practices throughout North Carolina. SUBJECTS Of the 721 primary care providers surveyed, 303 (42%) returned usable surveys. Respondents practiced in 89 of the 100 counties of the state served by NCCES family and consumer education agents. STATISTICAL ANALYSIS PERFORMED Descriptive statistics and independent sample t tests were used to analyze survey results. RESULTS Limited time with patients and inability to obtain materials because of cost or being unsure of sources were most often identified as barriers to using nutrition and wellness materials. Of the 26 topics surveyed, 6 had mean levels of need greater than or equal to high need (mean score > or = 4): weight control for adults, smoking cessation, changing dietary fat intake, exercise guidelines for healthy adults, general stress management guidelines, and healthful eating for older adults. Twenty-four of the 26 topics had mean levels of need greater than or equal to moderate need (mean score > or = 3). Topics with moderate need included guidelines for overweight children and adolescents, nutrition for chronic disease prevention, and healthful eating for various stages of the life cycle. The combined mean score for topics dealing with weight control and exercise for adults, adolescents, and children was greater than the score for high need (mean score > 4). Eighty-three percent of respondents preferred 1-page, printed handouts. Forty-five percent requested materials in Spanish. APPLICATIONS Dietitians who work in a variety of settings can use techniques similar to those described here to determine the patient education materials practitioners need for the populations they serve. The information obtained from this study will be used to develop 1-page, printed handouts. A registered dietitian and a food and nutrition specialist with NCCES will develop and pilot-test the handouts. These materials will be made available to primary care providers in North Carolina via local NCCES family and consumer education agents, many of whom are registered dietitians.

Black/White Differences in Risk Factors for Arteriographically Documented Coronary Artery Disease in Men

Although the leading cause of death among black men in the United States is coronary artery disease (CAD), risk factors have not been well documented in black populations. Therefore, possible racial differences in the relation of several characteristics to the extent of CAD were assessed in 4,722 white and 169 black men who underwent arteriography. Associations between an occlusion score (ranging from 0 to 300), reflecting the severity of CAD, and levels of total and high-density lipoprotein (HDL) cholesterol, triglycerides, cigarette smoking, alcohol intake, relative weight, systemic hypertension and diabetes mellitus were examined. Most risk factors were significantly related to the extent of CAD in both races, but lipid levels showed stronger associations with CAD among blacks: correlations between CAD and total cholesterol were 0.16 (whites) vs 0.29 (blacks) and associations with HDL cholesterol were -0.22 (whites) vs -0.49 (blacks). In addition, at adverse levels of certain risk factors, blacks had more extensive CAD than did whites: mean occlusion scores were 148 (whites) and 238 (blacks) at HDL cholesterol levels less than 30 mg/dl. As assessed by multiple linear regression, however, only triglyceride levels were differentially related to CAD between whites (beta = 0) and blacks (beta = 0.47), p less than 0.01 for racial contrast. These results document the importance of risk factors in black men and indicate black/white differences in the relation of triglycerides to CAD.

Cholesterol and coronary artery disease: Age as an effect modifier

An elevation of serum cholesterol has been one of the more frequently cited risk factors for coronary heart disease, found in both case-control and cohort studies. As a result, this country has undertaken massive screening of adults older than 20 years of age in an attempt to identify those persons with cholesterol levels greater than 200 mg/dl, and follow up with an active approach for intervention. The suggested cutpoints for borderline (200-240 mg/dl), and definite (> or = 240 mg/dl) hypercholesterolemia have been applied to all age groups despite suggestions of a diminution of risk conferred by cholesterol in the elderly. This study of 2544 white men undergoing coronary angiography shows that for all men, aged 25-84 years, plasma cholesterol levels were associated with an increase in coronary artery occlusion (rs = 0.15, p < 0.01). However, when stratified by age, this association held only for the younger men, the association diminishing to near zero in the oldest age group. The negative interaction between cholesterol levels and age in predicting coronary artery disease proved highly significant (p < 0.001) in multivariable linear regression analysis, suggesting that cholesterol levels are much less predictive of coronary artery disease in the elderly as compared to the young. These results point to the need for a more finely tuned set of criteria for the evaluation of hypercholesterolemia, one that takes into account the age of the screenee.