Cardiometabolic health after first pregnancy: Associations with social determinants of health. A nuMoM2b-HHS study.

Study objective: This study sought to evaluate the associations between social determinants of health (SDOH) at the time of first pregnancy and subsequent cardiometabolic health, defined as the development of metabolic syndrome. Design: nuMoM2b-HHS (Nulliparous Pregnancy Outcomes Study- Monitoring Mothers-to-Be-Heart Health Study) is an ongoing prospective cohort study. Setting: Eight academic medical centers enrolled and continue to follow participants. Participants: 4484 participants followed a mean of 3.2 years from the time of their first pregnancy. Interventions: N/a. Main outcome measure: Unadjusted and adjusted Poisson regression models with robust standard errors were used to obtain relative risks and 95% confidence intervals estimating the risk of metabolic syndrome for each baseline SDOH. In secondary analyses we examined the associations between SDOH and incident hypertension, obesity, and diabetes mellitus. Results: Metabolic syndrome developed in 13.6% of participants. Higher socioeconomic position at the time of pregnancy was associated with lower rates of metabolic syndrome [income > 200% poverty level aRR 0.55 (95% CI, 0.42-0.71), attainment of a bachelor's degree aRR 0.62 (0.46-0.84) or higher aRR 0.50 (0.35-0.71)], while being single [aRR 1.45 (95% CI, 1.18-1.77)] and having low health literacy were associated with a greater risk of metabolic syndrome [aRR 1.98 (95% CI, 1.28-3.07)]. Conclusions: Over a short interval following first pregnancy, participants accumulated high proportions of cardiovascular risk factors and metabolic syndrome, with some risk associated with SDOH. The impact of interventions addressing SDOH in pregnant people on cardiometabolic health should be tested as a means of reducing health inequities at the population level.

Cardiorespiratory fitness, exercise haemodynamics and birth outcomes: the Coronary Artery Risk Development in Young Adults Study.

OBJECTIVE: Determine associations of cardiorespiratory fitness, exercise systolic blood pressure (SBP) and heart rate recovery (HRR) following a maximal exercise test performed years preceding pregnancy with odds of preterm birth (PTB; <37 weeks' gestation) and small for gestational age (SGA; birthweight <10th percentile) delivery. DESIGN: Prospective, longitudinal. SETTING: Multi-site, observational cohort study initially consisting of 2787 black and white women aged 18-30 at baseline (1985-86) and followed for 25 years (Y25; 2010-2011). POPULATION: 768 nulliparous women at baseline who reported ≥1 live birth by the Y25 exam. METHODS: We used Poisson regression to determine associations of exposures with PTB/SGA. MAIN OUTCOME MEASURES: PTB and/or SGA births. RESULTS: Women with PTB (n = 143) and/or SGA (n = 88) were younger, had completed fewer years of education and were more likely to be black versus women without PTB/SGA (n = 546). Women with PTB/SGA had lower fitness (501 ± 9 versus 535 ± 6 seconds, P < 0.002) and higher submaximal SBP than women without PTB/SGA (144 ± 1 versus 142 ± 1 mmHg, P < 0.04). After adjustment, no exercise test variables were associated with PTB/SGA, though the association with HRR and submaximal SBP approached significance in the subset of women who completed the exercise test <5 years before the index birth. CONCLUSIONS: Neither fitness nor haemodynamic responses to exercise a median of 5 years preceding pregnancy, were associated with PTB/SGA. These findings indicate excess likelihood of PTB/SGA is not detectable by low fitness or exercise haemodynamic responses 5 years preceding pregnancy, but exercise testing, especially HRR and submaximal SBP, may be more useful when conducted closer to the onset of pregnancy. TWEETABLE ABSTRACT: Exercise testing conducted >5 years before pregnancy may not detect women likely to have PTB/SGA.

Coherent superpositions of three states for phosphorous donors in silicon prepared using THz radiation.

Superposition of orbital eigenstates is crucial to quantum technology utilizing atoms, such as atomic clocks and quantum computers, and control over the interaction between atoms and their neighbours is an essential ingredient for both gating and readout. The simplest coherent wavefunction control uses a two-eigenstate admixture, but more control over the spatial distribution of the wavefunction can be obtained by increasing the number of states in the wavepacket. Here we demonstrate THz laser pulse control of Si:P orbitals using multiple orbital state admixtures, observing beat patterns produced by Zeeman splitting. The beats are an observable signature of the ability to control the path of the electron, which implies we can now control the strength and duration of the interaction of the atom with different neighbours. This could simplify surface code networks which require spatially controlled interaction between atoms, and we propose an architecture that might take advantage of this.

Coherent creation and destruction of orbital wavepackets in Si:P with electrical and optical read-out.

The ability to control dynamics of quantum states by optical interference, and subsequent electrical read-out, is crucial for solid state quantum technologies. Ramsey interference has been successfully observed for spins in silicon and nitrogen vacancy centres in diamond, and for orbital motion in InAs quantum dots. Here we demonstrate terahertz optical excitation, manipulation and destruction via Ramsey interference of orbital wavepackets in Si:P with electrical read-out. We show milliradian control over the wavefunction phase for the two-level system formed by the 1s and 2p states. The results have been verified by all-optical echo detection methods, sensitive only to coherent excitations in the sample. The experiments open a route to exploitation of donors in silicon for atom trap physics, with concomitant potential for quantum computing schemes, which rely on orbital superpositions to, for example, gate the magnetic exchange interactions between impurities.

Sedentary behavior and blood pressure control among osteoarthritis initiative participants.

OBJECTIVE: To examine the association between sedentary behavior and blood pressure (BP) among Osteoarthritis Initiative (OAI) participants. DESIGN: We conducted a cross-sectional analysis of the OAI 48-month visit participants whose physical activity was measured using accelerometers. Participants were classified into four quartiles according to the percentage of wear time that was sedentary (<100 activity counts per min). Users of antihypertensive medications or non-steroidal anti-inflammatory drugs (NSAIDs) were excluded. Our main outcomes were systolic and diastolic blood pressures (SBP and DBP) and "elevated BP" defined as BP ≥ 130/85 mm Hg. RESULTS: For this study cohort (N = 707), mean BP was 121.4 ± 15.6/74.7 ± 9.5 mm Hg and 33% had elevated BP. SBP had a graded association with increased sedentary time (P for trend = 0.02). The most sedentary quartile had 4.26 mm Hg higher SBP (95% confidence interval (CI), 0.69-7.82; P = 0.02) than the least sedentary quartile, adjusting for age, moderate-to-vigorous (MV) physical activity, and other demographic and health factors. The probability of having elevated BP significantly increased in higher sedentary quartiles (P for trend = 0.046). There were no significant findings for DBP. CONCLUSION: A strong graded association was demonstrated between sedentary behavior and increased SBP and elevated BP, independent of time spent in MV physical activity. Reducing daily sedentary time may lead to improvement in BP and reduction in cardiovascular risk.

The initialization and manipulation of quantum information stored in silicon by bismuth dopants.

A prerequisite for exploiting spins for quantum data storage and processing is long spin coherence times. Phosphorus dopants in silicon (Si:P) have been favoured as hosts for such spins because of measured electron spin coherence times (T2) longer than any other electron spin in the solid state: 14 ms at 7 K with isotopically purified silicon. Heavier impurities such as bismuth in silicon (Si:Bi) could be used in conjunction with Si:P for quantum information proposals that require two separately addressable spin species. However, the question of whether the incorporation of the much less soluble Bi into Si leads to defect species that destroy coherence has not been addressed. Here we show that schemes involving Si:Bi are indeed feasible as the electron spin coherence time T2 is at least as long as for Si:P with non-isotopically purified silicon. We polarized the Si:Bi electrons and hyperpolarized the I=9/2 nuclear spin of (209)Bi, manipulating both with pulsed magnetic resonance. The larger nuclear spin means that a Si:Bi dopant provides a 20-dimensional Hilbert space rather than the four-dimensional Hilbert space of an I=1/2 Si:P dopant.

Coherent control of Rydberg states in silicon.

Laser cooling and electromagnetic traps have led to a revolution in atomic physics, yielding dramatic discoveries ranging from Bose-Einstein condensation to the quantum control of single atoms. Of particular interest, because they can be used in the quantum control of one atom by another, are excited Rydberg states, where wavefunctions are expanded from their ground-state extents of less than 0.1 nm to several nanometres and even beyond; this allows atoms far enough apart to be non-interacting in their ground states to strongly interact in their excited states. For eventual application of such states, a solid-state implementation is very desirable. Here we demonstrate the coherent control of impurity wavefunctions in the most ubiquitous donor in a semiconductor, namely phosphorus-doped silicon. In our experiments, we use a free-electron laser to stimulate and observe photon echoes, the orbital analogue of the Hahn spin echo, and Rabi oscillations familiar from magnetic resonance spectroscopy. As well as extending atomic physicists' explorations of quantum phenomena to the solid state, our work adds coherent terahertz radiation, as a particularly precise regulator of orbitals in solids, to the list of controls, such as pressure and chemical composition, already familiar to materials scientists.

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.

Classical versus quantum coherence.

Quantum dots are structures engineered to have desirable quantum-mechanical properties. Much of their potential usefulness stems from the ability to design such structures so that their passive properties can be exploited. However, there are many plans to use dots as the basis of a more active quantum engineering, in which the detailed quantum states of the dot's components are manipulated by externally imposed fields. This leads to a new requirement: our ability to model the time development of individual driven quantum systems. I shall discuss some of the problems which arise when single systems, rather than ensembles, are considered and give examples which illustrate the effects of classical and quantum incoherences. I propose a new classification of incoherent processes, based on their effect on individual wave functions.

Oats and soy in lipid-lowering diets for women with hypercholesterolemia: is there synergy?

OBJECTIVES: To study possible synergistic effects of oats and soy on reducing total and low-density lipoprotein cholesterol (LDL-C) concentrations in human beings and the efficacy and feasibility of including these adjustments to a National Cholesterol Education Program Step I diet. SUBJECT/SETTING: One hundred twenty-seven postmenopausal women with moderate hypercholesterolemia were recruited from a large Midwestern workforce and senior centers in the surrounding community. Intervention and clinical visits were conducted in these same facilities. DESIGN: After a 3-week lead-in period on the Step I diet, participants were randomly assigned to 1 of 4 dietary treatments for an additional 6 weeks: an oats/milk group, a wheat/soy group, an oats/soy group, and a wheat/milk group. Clinical measurements included blood draws, body weight and height, blood pressure, and medical history data. Three-day food records were collected at baseline and Weeks 3 and 9 of the intervention. Randomization was stratified based on the status of hormone replacement therapy and was blocked with sizes 4 or 8 for group assignment. RESULTS: After 3 weeks on the Step I diet, total cholesterol, LDL-C, and triglyceride levels; total fat and saturated fat intake, dietary cholesterol intake, Keys score, and body mass index were all reduced. Following an additional 6 weeks on the Step I diet plus intervention, total cholesterol and LDL-C were further reduced for both the oats/soy group and oats/milk group. There were no significant further changes in total cholesterol, LDL-C, or high-density lipoprotein cholesterol levels in the wheat/soy and wheat/milk groups. Body mass index remained stable in all groups from Week 3 to Week 9. APPLICATIONS: Nonpharmacologic dietary interventions like the Step I diet are feasible in a community setting and can produce rapid and significant lipid-lowering benefits. Daily consumption of 2 servings of oats can contribute to further lipid alterations in this population although soy intake at this dose may not. Palatability and convenience are important considerations in achieving dietary adherence.

Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment.

CONTEXT: Persons with lower-extremity peripheral arterial disease (PAD) are often asymptomatic or have leg symptoms other than intermittent claudication (IC). OBJECTIVE: To identify clinical characteristics and functional limitations associated with a broad range of leg symptoms identified among patients with PAD. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 460 men and women with PAD and 130 without PAD, who were identified consecutively, conducted between October 1998 and January 2000 at 3 Chicago-area medical centers. MAIN OUTCOME MEASURES: Ankle-brachial index score of less than 0.90; scores from 6-minute walk, accelerometer-measured physical activity over 7 days, repeated chair raises, standing balance (full tandem stand), 4-m walking velocity, San Diego claudication questionnaire, Geriatric Depression Score Short-Form, and the Walking Impairment Questionnaire. RESULTS: All groups with PAD had poorer functioning than participants without PAD. The following values are for patients without IC vs those with IC. Participants in the group with leg pain on exertion and rest (n = 88) had a higher (poorer) score for neuropathy (5.6 vs 3.5; P<.001), prevalence of diabetes mellitus (48.9% vs 26.7%; P<.001), and spinal stenosis (20.8% vs 7.2%; P =.002). The atypical exertional leg pain/carry on group (exertional leg pain other than IC associated with walking through leg pain [n = 41]) and the atypical exertional leg pain/stop group (exertional leg pain other than IC that causes one to stop walking [n = 90]) had better functioning than the IC group. The group without exertional leg pain/inactive (no exertional leg pain in individual who walks

Pulse pressure compared with other blood pressure indexes in the prediction of 25-year cardiovascular and all-cause mortality rates: The Chicago Heart Association Detection Project in Industry Study.

We compared the relations of 4 blood pressure (BP) indexes (pulse pressure [PP], systolic BP [SBP], diastolic BP [DBP], and mean arterial pressure [MAP]) with 25-year mortality rates for coronary heart disease (CHD), cardiovascular disease (CVD), and all causes in younger, middle-aged, and older men and women by using data from a long-term prospective epidemiological study of employed persons who were screened between 1967 and 1973. A single supine BP measurement was obtained at baseline. Vital status was determined through 1995. We report on 5 groups (total, 28 360 participants) consisting of men age 18 to 39, 40 to 59, and 60 to 74 years and of women age 40 to 59 and 60 to 74 years who were not receiving antihypertensive treatment, had no history of CHD, and did not have diabetes. Cox proportional hazards analyses were used to determine multivariate-adjusted hazard ratios with a 1-SD higher value for each BP index; Wald chi(2) tests were used to compare the strength of relations. Relations of PP were less strong than were those of SBP for all end points in all age/gender groups. SBP or MAP showed the strongest relations to all end points in all age/gender groups (hazard ratio, 1.17 to 1.36). The relations of SBP to death were stronger than were those of DBP, except for middle-aged men and for CVD in women. DBP showed significant positive associations with death, after control for SBP, in middle-aged participants. In conclusion, these data indicate that the long-term risk of high BP should be assessed mainly on the basis of SBP or of SBP and DBP together, not on the basis of PP, in apparently healthy adults.

Gait alterations associated with walking impairment in people with peripheral arterial disease with and without intermittent claudication.

OBJECTIVES: To describe gait alterations associated with impaired walking endurance in patients with and without lower-extremity peripheral arterial disease (PAD) and determine whether the Caltrac accelerometer provides a valid measure of physical activity in PAD. DESIGN: Cross-sectional. SETTING: Academic medical center. PARTICIPANTS: PAD (n = 40) and non-PAD patients (n = 22) from two Chicago hospitals. MEASUREMENTS: Participants underwent measurement of the ankle brachial index (ABI), leg length, and 6-minute walk. Steps per minute and step length were measured during the first and last 100 feet of the 6-minute walk. Participants wore a Caltrac accelerometer, sensitive to vertical acceleration, during the 6-minute walk and for 7 continuous days. RESULTS: Five PAD participants (13%) and one non-PAD participant (5%) ceased walking before the end of 6 minutes. Among the remaining participants, distance walked in 6 minutes was more highly related to walking velocity during the last 100 feet of the walk than walking velocity during the first 100 feet. ABI was associated significantly with cadence (20.77 steps/minute per unit ABI, P <.001) but not step length (10.12 centimeters/unit ABI, P =.08). ABI was associated significantly with 6-minute walk distance (493 feet/unit ABI, P =.018), but this association disappeared completely after adjustment for step length and cadence. We found no difference in accelerometer scores between PAD and non-PAD participants over a fixed distance of 800 feet (7.34 vs 7.17 activity units, P =.789). However, scores were significantly different after 7 days (730.8 vs 1,485.0 activity units, P =.003). CONCLUSION: Walking performance in PAD patients who completed 6 minutes of walking was largely determined by a decline in walking velocity rather than slower initial walking velocity. ABI was more closely associated with cadence than step length. Future studies should assess the effect of exercise programs and revascularization on cadence and step length in PAD.

Accuracy of estimating exercise prescription intensity in patients with left ventricular systolic dysfunction.

PURPOSE: Exercise prescription in patients with left ventricular systolic dysfunction (LVSD) is difficult. Exercising beyond ventilatory threshold (VT) can have negative physiologic effects; therefore, exercise prescribed above VT may be detrimental. A majority of cardiac rehabilitation programs use the Karvonen/heart rate reserve (HRR) method, rating of perceived exertion (RPE), and/or a percentage of oxygen consumption to prescribe exercise intensity. The purpose of this study was to determine if these methods correlate with an exercise intensity below VT in LVSD patients. METHODS: The authors studied 52 patients (37 males, 15 females; age 52 +/- 13 years; left ventricular ejection fraction 27% +/- 8%) who underwent a symptom-limited cardiopulmonary exercise test and reached VT to determine functional capacity and exercise prescription. RESULTS: Peak heart rate (HR) as well as HRR derived minimum (60%), midpoint (70%), and maximum (80%) HR were highly correlated (P < 0.001) with HR at VT. Using these three different HR cutoff formulas from HRR, 15% to 62% of patients were prescribed exercise outside the range of VT-HR +/- 10%. The midpoint (70% HRR) best predicted exercise HR in the VT-HR +/- 10% range (73% of patients). Mean oxygen consumption at VT was 83 +/- 9% of peak oxygen consumption. There was no correlation (P < 0.16) between RPE and VT. CONCLUSIONS: The Karvonen/HRR method failed to estimate HR-VT +/- 10% in a large percentage of patients with LVSD. There was no correlation between RPE and VT. Based on these data, exercise training intensity should ideally be prescribed based on the HR identified at VT using cardiopulmonary exercise testing in patients with LVSD.

Relationship of blood pressure to 25-year mortality due to coronary heart disease, cardiovascular diseases, and all causes in young adult men: the Chicago Heart Association Detection Project in Industry.

BACKGROUND: Data are limited on blood pressure (BP) in young adults and long-term mortality. Moreover, screening and hypertension treatment guidelines have been based mainly on findings for middle-aged and older populations. This study assesses relationships of BP measured in young adult men to long-term mortality due to coronary heart disease (CHD), cardiovascular diseases (CVD), and all causes. METHODS: This cohort from the Chicago Heart Association Detection Project in Industry included 10 874 men aged 18 to 39 years at baseline (1967-1973), not receiving antihypertensive drugs, and without CHD or diabetes. Relationship of baseline BP to 25-year CHD, CVD, and all-cause mortality was assessed. RESULTS: Age-adjusted association of systolic BP to CHD mortality was continuous and graded. Multivariate-adjusted CHD hazard ratios (HRs) for 1 SD higher systolic BP (15 mm Hg) and diastolic BP (10 mm Hg) were 1.26 (95% confidence interval [CI], 1.11-1.44) and 1.17 (95% CI, 1.01-1.35), respectively. Compared with the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure stratum with normal BP (and lowest mortality rates), the large strata with high-normal BP and stage 1 hypertension had 25-year absolute risks for death of 63 and 72 per 1000, respectively, and absolute excess risks of 10 and 20 per 1000, respectively; accounted for 59.8% of all excess CHD, CVD, and all-cause mortality; and were estimated to have life expectancy shortened by 2.2 and 4.1 years, respectively. CONCLUSIONS: In young adult men, BP above normal was significantly related to increased long-term mortality due to CHD, CVD, and all causes. Population-wide primary prevention, early detection, and control of higher BP are indicated from young adulthood on.

Prevalence and significance of unrecognized lower extremity peripheral arterial disease in general medicine practice*.

OBJECTIVE: To determine the prevalence of unrecognized lower extremity peripheral arterial disease (PAD) among men and women aged 55 years and older in a general internal medicine (GIM) practice and to identify characteristics and functional performance associated with unrecognized PAD. DESIGN: Cross-sectional. SETTING: Academic medical center. PARTICIPANTS: We identified 143 patients with known PAD from the noninvasive vascular laboratory, and 239 men and women aged 55 and older with no prior PAD history from a GIM practice. Group 1 consisted of patients with PAD consecutively identified from the noninvasive vascular laboratory (n = 143). Group 2 included GIM practice patients found to have an ankle brachial index less than 0.90, consistent with PAD (n = 34). Group 3 consisted of GIM practice patients without PAD (n = 205). MEASUREMENTS AND MAIN RESULTS: Leg functioning was assessed with the 6-minute walk, 4-meter walking velocity, and Walking Impairment Questionnaire (WIQ). Of GIM practice patients, 14% had unrecognized PAD. Only 44% of patients in Group 2 had exertional leg symptoms. Distances achieved in the 6-minute walk were 1,130, 1,362, and 1,539 feet for Groups 1, 2, and 3, respectively, adjusting for age, gender, and race (P <.001). The degree of difficulty walking due to leg symptoms as reported on the WIQ was comparable between Groups 2 and 3 and significantly greater in Group 1 than Group 2. In multiple logistic regression analysis including Groups 2 and 3, current cigarette smoking was associated independently with unrecognized PAD (odds ratio [OR], 6.82; 95% confidence interval [95% CI], 1.55 to 29.93). Aspirin therapy was nearly independently associated with absence of PAD (OR, 0.37; 95% CI, 0.12 to 1.12). CONCLUSION: Unrecognized PAD is common among men and women aged 55 years and older in GIM practice and is associated with impaired lower extremity functioning. Ankle brachial index screening may be necessary to diagnose unrecognized PAD in a GIM practice.

Risk factors for coronary heart disease in men 18 to 39 years of age.

BACKGROUND: Few studies have evaluated the long-term predictive capacity of risk factors for death from coronary heart disease in men younger than 40 years of age. OBJECTIVE: To assess the predictive capacity and discriminatory ability of major coronary risk factors in predicting death from coronary heart disease in young men. DESIGN: Prospective cohort study with 20 years of follow-up. SETTING: 84 companies in the Chicago area that participated in the Chicago Heart Association Detection Project in Industry (1967-1973). PARTICIPANTS: 11 016 men 18 to 39 years of age (mean age, 29.7 years) at baseline were the primary focus of this report; 8955 men 40 to 59 years of age at baseline served as a reference group. MEASUREMENTS: The main end point was death from coronary heart disease. RESULTS: All major risk factors-age, serum cholesterol level, systolic blood pressure, and cigarette smoking-were significantly associated with death from coronary heart disease over 20 years in young men. Relative risks for the major risk factors were of generally similar magnitude in young and middle-aged men. Receiver-operating characteristic curves for the best predictive model yielded an area under the curve of 0.82, indicating that standard risk factors were highly predictive of long-term outcome in young men. CONCLUSIONS: Major coronary disease risk factors, many of which are modifiable, are strong contributors to prediction of future risk, even in young men. These data may help in formulating appropriate strategies to identify young men at heightened risk for death from coronary heart disease in later adulthood.