Change in level of physical activity and risk of all-cause mortality or reinfarction: The Corpus Christi Heart Project.

BACKGROUND: The role of physical activity (PA) in reducing the risk of all-cause mortality or reinfarction after a first myocardial infarction (MI) remains unresolved, particularly for minority populations. The association between change in level of PA and risk of death or reinfarction was studied in 406 Mexican American and non-Hispanic white women and men who survived a first MI. METHODS AND RESULTS: MI patients were interviewed at baseline and annually thereafter about PA, medical history, and risk factors of coronary heart disease. Change in level of PA after the index MI was categorized as (1) sedentary, no change (referent group), (2) decreased activity, (3) increased activity, and (4) active, no change. Over a 7-year period, the relative risk (95% CI) of death was as follows: 0.21 (0.10 to 0.44) for the active, no change group; 0.11 (0.03 to 0.46) for the increased activity group; and 0.49 (0.26 to 0.90) for the decreased activity group. The relative risk of reinfarction was as follows: 0.40 (0.24 to 0.66) for the active, no change group; 0.22 (0.09 to 0.50) for the increased activity group; and 0.93 (0.59 to 1.42) for the decreased activity group. CONCLUSIONS: These findings are consistent with a beneficial role of PA for Mexican American and non-Hispanic white women and men who survive a first MI and have practical implications for the management of MI survivors.

The relation of diabetes to the severity of acute myocardial infarction and post-myocardial infarction survival in Mexican-Americans and non-Hispanic whites. The Corpus Christi Heart Project.

The effect of diabetes on survival after myocardial infarction (MI) was examined in a prospective population-based study of individuals hospitalized with MI in a bi-ethnic community of Mexican-Americans and non-Hispanic whites. Among Mexican-Americans, 54% (331 of 610) had diabetes compared with 33% (192 of 589) of non-Hispanic whites (P < 0.001). Among those with diabetes, the prevalence of a history of a cardiac event before the index admission was significantly higher (odds ratio = 1.4, 95% confidence interval [CI] 1.1-1.8) than among nondiabetic subjects. During the index hospitalization, diabetic subjects received cardiac catheterization less frequently than did nondiabetic subjects (45.1 vs. 51.5%, P = 0.03). Diabetic subjects had lower estimated ejection fractions, and the number of coronary arteries with significant obstruction (> 75%) was higher (P < 0.001). The peak creatine phosphokinase and creatine phosphokinase myocardial isoenzyme (CK-MB) levels were similar in diabetic and nondiabetic subjects. Despite a similar infarct size, diabetic subjects had a higher incidence of congestive heart failure (relative ratio = 2.2, 95% CI 1.7-2.8), more adverse indexes of short-term and long-term prognosis, and a longer average hospital stay (12.1 vs. 8.9 days, P < 0.01). After adjustment for age, sex, and ethnicity, the cumulative risk for total mortality, over 44 months of follow-up, was 37.4% among diabetic compared with 23.3% among nondiabetic subjects (P < 0.001). Diabetic subjects had a higher 28-day case-fatality rate post-MI as well as higher long-term mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Congestive heart failure in the United States: is there more than meets the I(CD code)? The Corpus Christi Heart Project.

BACKGROUND: Congestive heart failure (CHF) is increasing as a public health problem in the United States. The ability to quantify this problem has been limited by a lack of data regarding the validity of CHF identification. OBJECTIVE: To assess the validity of the use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD) codes to identify hospitalizations with clinical evidence of an episode of acute CHF in data of The Corpus Christi Heart Project, a population-based surveillance program for hospitalized coronary heart disease. METHODS: The validation standard was a composite variable including the presence of physician diagnosed acute CHF or radiographic evidence of pulmonary edema. Data were abstracted from the medical records of 5083 patients identified as hospitalized for possible acute myocardial infarction, aortocoronary bypass surgery, percutaneous transluminal coronary angioplasty, and related revascularization procedures in the Corpus Christi Heart Project. Discharge diagnoses, a secondary source of data, were used to apply 3 computer algorithms to assess the assignment of ICD codes. RESULTS: The prevalence of clinically documented CHF was 27.1% (1376/5083). The ICD code 428 (CHF), assigned as the primary or a secondary discharge diagnosis, was associated with 62.8% sensitivity, 95.4% specificity, 83.5% positive predictive value, 87.4% negative predictive value, and a 24.8% underenumeration of CHF-related hospitalizations. An algorithm based on a series of ICD codes was associated with 67.1% sensitivity, 92.6% specificity, 77.1% positive predictive value, 88.3% negative predictive value, and a 13.0% underenumeration of CHF-related hospitalizations. CONCLUSIONS: Reliance on ICD codes results in the exclusion of one third of the patients with clinical evidence of acute CHF. This underenumeration is compounded by the typical reliance on the first listed diagnosis. Congestive heart failure may be a greater public health problem than currently recognized. The allocation of resources for relevant surveillance, research, medical care, and preventive efforts should be reevaluated.

Knowledge of heart attack symptoms in a population survey in the United States: The REACT Trial. Rapid Early Action for Coronary Treatment.

BACKGROUND: Greater use of thrombolysis for patients with myocardial infarction has been limited by patient delay in seeking care for heart attack symptoms. Deficiencies in knowledge of symptoms may contribute to delay and could be a target for intervention. We sought to characterize symptom knowledge. METHODS: Rapid Early Action for Coronary Treatment is a community trial designed to reduce this delay. At baseline, a random-digit dialed survey was conducted among 1294 adult respondents in the 20 study communities. Two open-ended questions were asked about heart attack symptom knowledge. RESULTS: Chest pain or discomfort was reported as a symptom by 89.7% of respondents and was thought to be the most important symptom by 56.6%. Knowledge of arm pain or numbness (67.3%), shortness of breath (50.8%), sweating (21.3%), and other heart attack symptoms was less common. The median number of correct symptoms reported was 3 (of 11). In a multivariable-adjusted model, significantly higher mean numbers of correct symptoms were reported by non-Hispanic whites than by other racial or ethnic groups, by middle-aged persons than by older and younger persons, by persons with higher socioeconomic status than by those with lower, and by persons with previous experience with heart attack than by those without. CONCLUSIONS: Knowledge of chest pain as an important heart attack symptom is high and relatively uniform; however, knowledge of the complex constellation of heart attack symptoms is deficient in the US population, especially in low socioeconomic and racial or ethnic minority groups. Efforts to reduce delay in seeking medical care among persons with heart attack symptoms should address these deficiencies in knowledge.

Obesity in Hispanic Americans.

The prevalence of obesity among Hispanic American populations is generally greater than among white populations in the United States. Among Mexican Americans, the prevalence of obesity was higher than among either Cuban Americans or Puerto Ricans. It is well known that the prevalence of diabetes increases with increasing levels of obesity or body mass index. However, it does not appear that the high prevalence of obesity in Mexican Americans completely accounts for the higher prevalence of diabetes seen in this ethnic group. Among Mexican Americans, the association of selected cardiovascular disease risk factors, high-density lipoprotein cholesterol subfractions and systolic blood pressure, was similar to that seen among other U.S. populations. Individuals with diabetes had higher values than seen among those without diabetes. In a comparison of nutrient intake in two Mexican-American populations, one rural and one urban, there were no major differences other than higher calorie intakes in the rural population compared with the urban population. In addition, the diet in the rural population, based on higher levels of the Keys score, was more atherogenic than that of the urban population.

Attained growth status of selected groups of Israeli children.

Analyses of available growth data from different groups of Israeli children revealed wide differences in attained growth in groups of children whose parents immigrated from different countries. By means of analyses of variance, it was shown that these differences in growth are most likely due to differences in the socioeconomic level of the family, rather than being related to parental country of origin. The data also suggest that nutrition problems among Israeli children, although not very severe, reflect a moderate degree of maldistribution of available food resources in different socioeconomic and cultural subgroups. The data also support the applicability and usefulness of a reference population data base drawn from children in the United States, in evaluating the attained growth status of children in different population groups.

Findings relating to goiter and iodine in the Ten-State Nutrition Survey.

Examinations for thyroid size were carried out on 35,999 individuals in the Ten-State Nutrition Survey. Overall goiter prevalence was found to be 3.1 per cent with the higher prevalence of goiter among adolescents and adults. Females of all ages had a higher prevalence of goiter than did males. No consistent regional pattern of the occurrence of goiter was observed. Urinary iodine excretion values used to estimate iodine intake indicated very few persons with excretion values suggesting iodine deficiency. No association between goiter and low iodine excretion was observed. On the contrary, a higher prevalence of goiter was found among persons excreting high levels of iodine. There is no indication from this study of widespread, iodine-deficiency goiter.

Hemoglobins and hematocrits: are they equally sensitive in detecting anemias?

General medical and nutritional practice assumes that hemoglobin and hematocrit values are equally useful in detecting anemia and that they can be used interchangeably for anemia screening. These two tests, at presumed equivalent levels, identify varying prevalences of anemia in the same population. This study examines anemia prevalence rates using hemoglobin and hematocrit tests performed in seven separate surveys on a total of 13,040 children. These data indicate that hemoglobin and hematocrit screening tests are indeed not comparable in detecting anemia in the same population. Using only hematocrit tests, anemia is diagnosed in 1 to 10% of children with normal hemoglobin levels and is not detected in 20 to 50% of children who might be considered anemic on the basis of low hemoglobin levels.

Ischemic heart disease: footprints through the data.

This study addresses the question of whether the rise in ischemic heart disease mortality has been just "a paper epidemic" as asserted in an earlier issue of this journal. Age-standardized death rates, proportions expected to die, mean ages at death, and cause specific contributions to changes in overall life expectancies were calculated for acute and chronic ischemic heart disease and for males and females for the years 1931 to 1980 using published vital statistics data. These multiple analyses reveal: a true epidemic of acute ischemic heart disease has occurred, affecting males exclusively or to a greater degree than females and it is now on the decline, fairly stable and more nearly comparable mortality for both males and females for chronic ischemic heart disease, and continuing problems of classification obscure the true levels of mortality for both the acute and chronic entities.

Perspectives on the School Nutrition Dietary Assessment Study from the Child and Adolescent Trial for Cardiovascular Health.

The School Nutrition Dietary Assessment Study provides current data on the nutritional quality and adequacy of the National School Lunch Program (NSLP) and the School Breakfast Program (SBP) as well as on the dietary intakes of students participating in these programs. The study demonstrates that the NSLP and SBP meals and children's total diets do not conform to the recommendations of the US Department of Agriculture and the National Research Council and confirms the need to improve the nutritional quality of the nation's school meal program and student's overall dietary intakes. In this regard, the Child and Adolescent Trial for Cardiovascular Health (CATCH) is the first collaborative, school-based field trial that tests the effectiveness of a multi-level intervention designed to reduce the fat, saturated fat, and sodium content of school meals and student's diets. This commentary highlights the findings and questions raised by the School Nutrition Dietary Assessment Study and presents an overview of CATCH, including the implications and significant questions that can be addressed by this intervention study.

Community-wide coronary heart disease mortality in Mexican Americans equals or exceeds that in non-Hispanic whites: the Corpus Christi Heart Project.

PURPOSE: Previous comparisons of coronary heart disease mortality between Mexican Americans and non-Hispanic whites have given paradoxic results: despite their adverse cardiovascular risk profiles, especially a greater prevalence of diabetes, Mexican Americans are reported to have lower rates of mortality from coronary heart disease. SUBJECTS AND METHODS: We performed a community-based surveillance among all residents of Nueces County, Texas, aged 25 to 74 years, from 1990 to 1994. All death certificates were obtained and coded, and deaths potentially related to coronary heart disease were selected and validated by standardized methods blinded to ethnicity. Validated in-hospital and out-of-hospital coronary heart disease mortality was compared between 785 Mexican Americans and 862 non-Hispanic white women and men. RESULTS: Validated coronary heart disease mortality in Mexican Americans exceeded that for non-Hispanic whites in the same community. Among women, definite coronary heart disease mortality was 40% greater among Mexican Americans (rate ratio [RR] 1.43, 95% confidence interval [CI]: 1.12 to 1.82), as was all coronary heart disease mortality (RR, 1.32, 95% CI: 1.08 to 1.63). Among men, Mexican Americans had greater rates of all (RR, 1.11; 95% CI: 0.96 to 1.28) and definite coronary heart disease mortality (RR, 1.16; 95% CI: 0.91 to 1.47), but the associations were not statistically significant. CONCLUSIONS: When community-wide mortality rates from coronary heart disease are properly validated, Mexican Americans have rates equal to or higher than those of non-Hispanic whites. Community-based surveillance with validation of coronary heart disease as the cause of death is necessary to avoid the errors that occur with the use of death certificates alone.

Iodine and goiter in children.

Goiter examination was performed on 7,785 children aged 9 to 16 years in four areas of the United States--Michigan, Kentucky, Texas, and Georgia. Urinary iodine and creatinine, thyroxine, protein-bound iodine, and plasma inorganic iodide determinations were made on 377 matched pairs of goitrous and nongoitrous control children. The overall prevalence of goiter was 6.8%. Most children with goiter had palpably but not visibly enlarged thyroids and showed no evidence of clinical or biochemical thyroid abnormalitymmean urinary iodine excretion was 452 mug/gm of creatinine, many times the 50 mug/gm of creatinine level used to define deficiency. Children with goiter and areas with high goiter prevalence tended to have higher rather than lower iodine excretion. These findings are consistent with other data indicating high iodine intakes in the United States and suggest that goiter in American children cannot be assumed to be related to iodine deficiencymthe possible role of high iodine intake in the causation of goiter is discussed.

Intake and food sources of dietary fat among schoolchildren in The Woodlands, Texas.

To investigate the nutrient intake and food use patterns among schoolchildren, diet was assessed among 138 children and adolescents in grades 5 through 12 using three random, nonconsecutive, 1-day food records. Mean intake of total fat, saturated fat, and polyunsaturated fat as percent of calories was 35.6%, 13.4%, and 6.6%, respectively. Among all subjects, 17% consumed diets containing less than 30% of calories from fat, 34% consumed greater than or equal to 38% of calories from fat, 7% consumed less than 10% of calories from saturated fatty acids, and greater than 97% ate less than 300 mg of cholesterol per day. While intake of calories, sodium, and beta-carotene per 1000 kcal was higher in subjects consuming higher fat diets, intake of other micronutrients was either higher among those eating low-fat diets or did not differ by level of fat intake. Differences were seen in the amount of saturated fat and cholesterol that individual food sources contributed to the diets of subjects eating high and low fat diets. These cross-sectional data show that a substantial proportion of children and adolescents in this population are consuming diets low in fat and cholesterol without systematic differences in intake of other nutrients, suggesting that current dietary guidelines regarding fat intake are attainable within the current food use pattern of healthy, school-aged children and adolescents.

Hospitalization rates for myocardial infarction among Mexican-Americans and non-Hispanic whites. The Corpus Christi Heart Project.

The rate of hospitalization for myocardial infarction was examined in the Corpus Christi Heart Project (CCHP), a prospective population-based surveillance program in a biethnic community of Mexican-Americans and non-Hispanic whites. During 12 months of ascertainment, a total of 740 patients hospitalized with definite (217) or possible (523) myocardial infarction were identified. Of the 740 subjects, 334 were Mexican-Americans (150 females and 184 males), 348 were non-Hispanic whites (138 females and 210 males), and 58 were of other ethnic backgrounds. The 1-year age-adjusted rates of hospitalization per 100,000 population were 427.4 and 276.9 among Mexican-American and non-Hispanic white females, respectively, and 721.4 and 502.6 among Mexican-American and non-Hispanic white males, respectively. The age-adjusted hospitalization rate ratios for Mexican-Americans in relation to non-Hispanic whites were 1.55 (95% confidence interval [CI]: 1.23 to 1.95) and 1.40 (95% CI: 1.15 to 1.70) for females and males, respectively. These results suggest that Mexican-Americans may have a greater burden of coronary disease than non-Hispanic whites.

A population-based assessment of the use and effectiveness of thrombolytic therapy. The Corpus Christi Heart Project.

Little is known regarding the use and effectiveness of thrombolytic therapy in community settings, especially regarding the receipt of therapy by Mexican Americans. Thus, we examined the factors associated with receipt of thrombolysis and the survival experience of recipients and nonrecipients in the Corpus Christi Heart Project. The Corpus Christi Heart Project is a population-based surveillance program for hospitalized myocardial infarction among Mexican-American and non-Hispanic white women and men residing in Corpus Christi, Texas. Multivariate regression analyses were used to identify factors associated with receipt of thrombolytic therapy and to assess the association between receipt of thrombolytic therapy and mortality. During a 2-year period, 1199 patients hospitalized for myocardial infarction were identified; 159 (13.3%) received thrombolysis. Among "ideal" candidates for thrombolytic therapy, 74 (35.1%) of 211 received such therapy. Women were less likely to receive thrombolysis than men, and Mexican Americans were less likely to received thrombolysis than non-Hispanic whites. Patients for whom there was a delay of more than 4 hours between onset of symptoms and arrival at the hospital were also less likely to receive thrombolysis. Recipients of thrombolytic therapy experienced lower mortality over 56 months following myocardial infarction than did nonrecipients (20.5 versus 33.2%, P < 0.01). Use of thrombolytic therapy was less frequent among women and Mexican Americans than among men and non-Hispanic whites, and was limited by delay between onset of symptoms and arrival at the hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

Food-frequency questionnaire validation among Mexican-Americans: Starr County, Texas.

A food-frequency questionnaire (FFQ) for low-income Mexican-Americans in Starr County, Texas, was developed as part of an epidemiologic study of gallbladder disease during 1985 and 1986. The FFQ was developed from 7-day food records collected from the first sample. In the validity study, using the second sample, correlations between nutrients calculated from 3-day food records and the FFQ were 0.77, 0.76, and 0.61 for energy, total fat, and saturated fat, respectively. In the reliability study, using the third sample, for the 1-month interval between baseline and a repeat FFQ measurement correlations ranged from 0.90 for energy to 0.85 for total fat and for the 2-month interval they were 0.84 for energy and 0.70 for total fat. The high correlations are largely explained by the lack of diversity in the diets of Starr County individuals which facilitated the high agreement between the FFQ and the food records for estimates of energy, fats, and cholesterol.

Sex and ethnic differences in use of myocardial revascularization procedures in Mexican Americans and non-Hispanic whites: the Corpus Christi Heart Project.

Age-adjusted rates of percutaneous transluminal coronary angioplasty (PTCA) and aortocoronary bypass surgery (ACBS) were determined for Mexican American (MA) and non-Hispanic white (NHW) patients hospitalized for coronary heart disease. Hypotheses of equal receipt of procedures between gender and ethnic groups were tested. Following myocardial infarction (MI), women were less likely than men to receive either procedure (22 versus 32%, p < 0.01), and MA were less likely than NHW to receive PTCA (13 versus 23%, p < 0.01) but not ACBS. After adjustment for extent of disease and other potential confounders, ethnic groups differed marginally in receipt of PTCA but not ACBS, while gender differences were not significant. Although women received revascularization procedures less frequently than men, this difference did not persist after controlling for extent of coronary artery disease by angiography: therefore, these observed differences in delivery of health care services may be appropriate. Mexican Americans received PTCA, but not ACBS, less frequently than NHW. This selective ethnic difference in receipt of PTCA does not appear to be associated with the extent of disease or other medical characteristics, and may represent inappropriate bias in delivery of health care services.

Women and Mexican Americans receive fewer cardiovascular drugs following myocardial infarction than men and non-Hispanic whites: the Corpus Christi Heart Project, 1988-1990.

Mortality following myocardial infarction (MI) is greater among women than men and among Mexican Americans than non-Hispanic whites. Because therapy can affect mortality following MI, we examined differences in discharge therapy among these groups. Data regarding discharge therapy of 982 patients in the Corpus Christi Heart Project showed that women received fewer cardiovascular drugs than men, and Mexican Americans received fewer cardiovascular drugs than non-Hispanic whites. In multivariate analysis adjusting for age, cigarettes smoking, diabetes, hypertension, congestive heart failure, and serum cholesterol, the odds ratio for receipt of cardiovascular medications was 0.51 (95% CI: 0.28-0.93) for women versus men and 0.62 (0.3-1.15) for Mexican Americans versus non-Hispanic whites. Beta-blockers were prescribed rarely. Thus, treatment differences between ethnic and gender groups were observed following MI. Further research is needed to determine both the reasons for these differences and the extent to which these differences contribute to the observed survival patterns following MI.

An assessment of the validity of ICD Code 410 to identify hospital admissions for myocardial infarction: The Corpus Christi Heart Project.

BACKGROUND: The identification of myocardial infarction (MI) is typically based on finding events designated by a nosologist with the appropriate International Classification of Diseases (ICD) code, currently code 410. These codes are applied based on review of medical records or death certificates. However, other factors, including reimbursement considerations, may influence the coding process, especially for hospitalizations. Thus, the validity of using ICD code 410 to identify MI must be assessed. METHODS: The Corpus Christi Heart Project (CCHP) is a population-based surveillance programme for hospitalized MI. Patients were identified using concurrent ascertainment in coronary care units and retrospective review of medical records. Events were validated as definite or possible MI using data regarding chest pain, electrocardiographic changes and cardiac enzymes. The validity of using ICD code 410 to identify cases of MI was assessed by calculating the sensitivity, specificity, predictive values and efficiency of ICD code 410 versus the CCHP 'gold standard'. RESULTS: Use of ICD code 410 identified 80.9% (401/496) of definite MI, but only 19.0% (243/1280) of possible MI. Only 12.3% (90/734) of discharges with an ICD 410 code received a 'no MI' designation based on the 'gold standard'. The efficiency of ICD code 410 for identifying MI was 92.0% for definite MI and 77.1% for definite and possible MI. CONCLUSIONS: The use of ICD code 410 to identify hospitalized cases of MI results in a modestly biased overestimate of the number of definite MI hospitalizations; however, this approach warrants consideration due to the expense of validation procedures.

Higher blood pressure in middle-aged American adults with less education-role of multiple dietary factors: the INTERMAP study.

Extensive evidence exists that an inverse relation between education and blood pressure prevails in many adult populations, but little research has been carried out on reasons for this finding. A prior goal of the INTERMAP Study was to investigate this phenomenon further, and to assess the role of dietary factors in accounting for it. Of the 4680 men and women aged 40-59 years, from 17 diverse population samples in Japan, People's Republic of China, UK, and USA, a strong significant inverse education-BP relation was manifest particularly for the 2195 USA participants, independent of ethnicity. With participants stratified by years of education, and assessment of 100+ dietary variables from four 24-h dietary recalls and two 24-h urine collections/person, graded relationships were found between education and intake of many macro- and micronutrients, electrolytes, fibre, and body mass index (BMI). In multiple linear regression analyses with systolic BP (SBP) and diastolic BP (DBP) of individuals the dependent variables (controlled for ethnicity, other possible nondietary confounders), BMI markedly reduced size of education-BP relations, more so for women than for men. Several nutrients considered singly further decreased size of this association by > or =10%: urinary 24-h Na and K excretion, Keys dietary lipid score, vegetable protein, fibre, vitamins C and B6, thiamin, riboflavin, folate, calcium, magnesium, and iron. Combinations of these dietary variables and BMI attenuated the education-SBP inverse coefficient by 54-58%, and the education-DBP inverse coefficient by 59-67%, with over half these effects attributable to specific nutrients (independent of BMI). As a result, the inverse education-BP coefficients ceased to be statistically significant. Multiple specific dietary factors together with body mass largely account for the more adverse BP levels of less educated than more educated Americans. Special efforts to improve eating patterns of less educated strata can contribute importantly to overcoming this and related health disparities in the population.