Hormone replacement therapy and colorectal adenoma recurrence among women in the Polyp Prevention Trial.

BACKGROUND: Epidemiologic studies have suggested that estrogen may protect against the development of colorectal cancers and adenomatous polyps. We conducted a prospective study to evaluate the association between hormone replacement therapy (HRT) and adenoma recurrence among perimenopausal and postmenopausal women participating in the Polyp Prevention Trial, a randomized dietary intervention study of individuals with colorectal adenomas. METHODS: We used a questionnaire and interviews to collect detailed information, at baseline and at each of four annual study visits, from 620 women regarding hormone use, menopausal status, diet, alcohol consumption, and other risk factors. Adenoma recurrence was ascertained by complete colonoscopy at baseline and after 1 and 4 years. Logistic regression models were used to evaluate the association between hormone use and adenoma recurrence after adjusting for intervention group and for age and body mass index at baseline. All statistical tests were two-sided. RESULTS: Adenomas recurred in 200 women. There was no overall association between adenoma recurrence and either overall hormone use (odds ratio [OR] = 1.01; 95% confidence interval [CI] = 0.70 to 1.45), combined estrogen and progestin use (OR = 0.94; 95% CI = 0.57 to 1.56), or unopposed estrogen use (OR = 1.04; 95% CI = 0.68 to 1.59). HRT use was associated with a reduction in risk for recurrence of distal adenomas (OR = 0.56; 95% CI = 0.32 to 1.00) and a statistically nonsignificant increase in risk for recurrence of proximal adenomas (OR = 1.39; 95% CI = 0.85 to 2.26). We observed a statistically significant interaction between the HRT-adenoma recurrence association and age (P =.02). HRT was associated with a 40% reduced risk of adenoma recurrence among women older than 62 years (OR = 0.58; 95% CI = 0.35 to 0.97) but with an increased risk among women younger than 62 years (OR = 1.99; 95% CI = 1.11 to 3.55). CONCLUSIONS: HRT was not associated with a reduced risk for overall adenoma recurrence in this trial cohort, although there was a suggestion of an age interaction. The effect of age on the association needs to be confirmed in other adenoma recurrence trials.

Retinal arteriolar diameters and elevated blood pressure: the Atherosclerosis Risk in Communities Study.

Narrowing and other changes in retinal arterioles may reflect damage due to hypertension, which may predict stroke and other cardiovascular diseases independently of blood pressure level. Newly developed quantitative methods of assessing retinal narrowing are used to determine whether this sign is related only to current blood pressure or whether it also independently reflects the effects of previous blood pressure. Retinal photography was performed at the third examination of Atherosclerosis Risk in Communities (ARIC) Study in 1993-1995, and results are presented for the 9,300 nondiabetic participants aged 50-71 years. Generalized narrowing of smaller arterioles was strongly and monotonically related to current blood pressure in men and women, whether they were taking antihypertensive medications or not, and, independent of current blood pressure, was consistently and monotonically related to blood pressure levels measured 3 and 6 years before the retinal assessment. Arteriovenous nicking was also independently related to both current and previous blood pressures. The patterns of association suggested that these signs reflect both transient and persisting structural effects of elevated blood pressure, in agreement with the scant pathologic literature available. The findings suggest that retinal assessment may be useful for research on the microvascular contributions to clinical cardiovascular diseases.

Pulmonary function testing in population-based studies.

A wealth of information on pulmonary function is currently available in NHLBI-sponsored, population-based studies. These data can be used to address critically important questions in pulmonary and cardiovascular disease research, but their potential cannot be realized without the active collaboration of pulmonary- and cardiovascular-disease researchers. Investigators interested in analyzing these data in collaboration with the parent study investigators are invited to contact these investigators directly (see APPENDIX). Results of analyses recommended in the workshop should be used to identify hypotheses for future efforts in collecting data on the epidemiology of pulmonary diseases and their relationship to cardiovascular disease.

Risk factors and segment-specific carotid arterial enlargement in the Atherosclerosis Risk in Communities (ARIC) cohort.

BACKGROUND AND PURPOSE: B-mode ultrasound imaging affords the opportunity to quantify both intimal-medial thickness (IMT) and lumen diameter of extracranial carotid arteries in ambulatory populations. Since the relation of IMT to lumen diameter may be complex, we asked whether cardiovascular disease risk factors (previously shown to be associated with greater arterial IMT) are related to smaller lumen diameters. METHODS: We used B-mode ultrasound to quantify lumen diameter, interadventitial diameter, and IMT of the extracranial carotid arteries and assessed the relationship of these measures to body mass index, smoking, low-density lipoprotein (LDL) and high-density lipoprotein cholesterol, hypertension, and diabetes in 6088 male and 7493 female participants in the Atherosclerosis Risk in Communities (ARIC) cohort. RESULTS: Smoking, hypertension, and LDL cholesterol were consistently related to greater IMT in the common and internal carotid arteries of men and women, as has been previously reported. In the internal carotid artery, smoking, hypertension, and LDL cholesterol were consistently related to smaller lumens. In the common carotid artery, body mass index, smoking, and hypertension were related to significantly larger, and LDL cholesterol to smaller, lumens. Thus, only LDL cholesterol was consistently associated with smaller lumens in both the common and internal carotid arteries. CONCLUSIONS: Risk factors relate positively to IMT in both the common and internal carotid arteries and inversely with lumen diameter in the internal carotid artery, in parallel with their relation to clinical events. However, their association with lumen diameters of the common carotid artery in population-based samples is more complex, and in some cases adverse levels of risk factors may be associated with larger lumens.

Arterial enlargement in the atherosclerosis risk in communities (ARIC) cohort. In vivo quantification of carotid arterial enlargement. The ARIC Investigators.

BACKGROUND AND PURPOSE: The relation between arterial wall (intimal-medial) thickness and lumen narrowing is complex and has previously been studied predominantly at autopsy. B-mode ultrasound affords the opportunity to visualize both wall and lumen of the extracranial carotid arteries in vivo. Several studies have quantified the relation of various independent variables to wall thickness of carotid arteries in population-based samples, but the relation of age and wall thickness to interadventitial and lumen diameter has not previously been investigated in these samples. METHODS: We used B-mode ultrasound to quantify the relation of arterial lumen diameter to age, arterial wall thickness, and arterial size (interadventitial diameter) of the extracranial carotid artery in 13,711 members of the Atherosclerosis Risk in Communities (ARIC) cohort. RESULTS: Men had greater interadventitial diameters, thicker walls, and wider lumens than women. Wall thicknesses of the common carotid artery were greater by 21% in men and 22% in women aged 60 to 64 years compared with those aged 45 to 49 years (P < .001). However, lumen diameters were also greater in older individuals because interadventitial diameters were greater. Wall thickness of the internal carotid artery was also associated positively with age, but the lumen diameter of the internal carotid artery was smaller in older individuals. Diameters of the carotid artery segments also differed in their relation to arterial wall thickening. The lumen of the internal carotid artery was uniformly progressively narrower with increasing wall thickness. For the common carotid artery greater wall thickness bore only a small correlation with narrower lumen diameter for thickening of the arterial wall up to 1.2 mm, but the association was more marked for the range of thicknesses between 1.2 mm and 2.5 mm. CONCLUSIONS: When arterial enlargement accompanies increased wall thickness, less lumen constriction results than expected. Quantification of these complex relations in vivo may provide new insight into the pathogenesis of symptoms related to vascular disease. Narrowing of the internal carotid artery lumen associated with thicker walls is consistent with the observation that stenosis develops in this region and often leads to symptoms.

The epidemiology of heart failure: the Framingham Study.

Congestive heart failure has become an increasingly frequent reason for hospital admission during the last 2 decades and clearly represents a major health problem. Data from the Framingham Heart Study indicate that the incidence of congestive heart failure increases with age and is higher in men than in women. Hypertension and coronary heart disease are the two most common conditions predating its onset. Diabetes mellitus and electrocardiographic left ventricular hypertrophy are also associated with an increased risk of heart failure. During the 1980s, the annual age-adjusted incidence of congestive heart failure among persons aged > or = 45 years was 7.2 cases/1,000 in men and 4.7 cases/1,000 in women, whereas the age-adjusted prevalence of overt heart failure was 24/1,000 in men and 25/1,000 in women. Despite improved treatments for ischemic heart disease and hypertension, the age-adjusted incidence of heart failure has declined by only 11%/calendar decade in men and by 17%/calendar decade in women during a 40-year period of observation. In addition, congestive heart failure remains highly lethal, with a median survival time of 1.7 years in men and 3.2 years in women and a 5-year survival rate of 25% in men and 38% in women.

Benefits and adverse effects of weight loss. Observations from the Framingham Study.

OBJECTIVE: To identify the benefits and adverse effects of weight loss. DESIGN: Longitudinal, epidemiologic study in a defined population. PARTICIPANTS: Men and women (n = 2500) who were between 35 and 54 years old at baseline, followed for 20 years in Framingham, Massachusetts. MEASUREMENTS: Height, weight, lipid levels, blood pressure, smoking status, diet, physical activity, prevalent and incident cardiovascular disease, diabetes, other diseases, and mortality rate were assessed. RESULTS: Compared with those whose body mass index (BMI) or weight changed least, men and women who lost weight during a 10-year period were older, heavier, and had higher blood pressures and cholesterol levels initially but had the smallest gains in blood pressure and cholesterol levels. However, rates of cigarette smoking were higher, and rates of smoking cessation were lower. During 20 years of further follow-up, death rates were highest in those whose BMI decreased and in those with the highest BMI at study entry. Relative risks for death from cardiovascular disease, coronary heart disease, and all causes were significantly greater by 33% to 61% in men whose BMI decreased after adjusting for age and risk factors for cardiovascular disease. In women, weight loss and weight gain were associated with higher relative risks for cardiovascular disease and coronary heart disease, but only the 38% increase in total mortality rate among women who lost weight was statistically significant after adjusting for age. CONCLUSIONS: Weight loss was associated with improvements in blood pressure and cholesterol levels but also with continued cigarette smoking, prevalent and incident cardiovascular disease, diabetes mellitus, other diseases, and higher death rates. Leanness and maintenance of stable weight were beneficial to risk factors, and to the prevention of morbidity, and death.

Myocardial infarction and coronary death among women: psychosocial predictors from a 20-year follow-up of women in the Framingham Study.

This study investigates the relation of psychosocial variables to the 20-year incidence of myocardial infarction or coronary death among women in the Framingham Study. In 1965-1967, a psychosocial interview was given along with the collection of other coronary risk factor data. This study includes 749 women aged 45-64 years who were free of coronary disease at this baseline examination. Demographic variables, psychosocial scales (such as tension and reactions of anger), and individual interview items (such as attitudes toward children, money, and religion) were measured. When age, systolic blood pressure, the ratio of serum total cholesterol to high-density lipoprotein cholesterol, diabetes, cigarette smoking, and body mass index were controlled for in multivariate proportional hazards models, the predictors of the 20-year incidence of myocardial infarction or coronary death were as follows: among employed women, perceived financial status only; among homemakers, symptoms of tension and anxiety, being lonely during the day, difficulty falling asleep, infrequent vacations, housework affecting health, and believing one is prone to heart disease (p less than 0.05 for all variables); and among both groups of women combined, low educational level, tension, and lack of vacations. These results are discussed in relation to previous findings from the Framingham Study.

The Framingham Disability Study: relationship of various coronary heart disease manifestations to disability in older persons living in the community.

The relation between coronary heart disease and disability was examined in 2,576 community-dwelling women and men ages 55-88 years. These Framingham Study participants were originally recruited in 1948-51 for an examination of cardiovascular disease. Twenty-seven years later, remaining members of the cohort were interviewed to ascertain physical abilities, and a score on a disability scale was assigned. Multivariate logistic analyses examined disability in relation to uncomplicated angina pectoris (AP), complicated AP, and coronary heart disease other than AP, controlling for possible confounders. In younger and older women and men, uncomplicated and complicated AP were associated with disability. Coronary heart disease other than AP was associated with disability only in the younger men. Congestive heart failure predicted disability only in the women. These results suggest that onset of AP should be recognized as a critical point in the development of disability and that AP is a better predictor of disability than is myocardial infarction or coronary insufficiency.

The Framingham Disability Study: physical disability among community-dwelling survivors of stroke.

The relationship between stroke and physical disability was examined in a cohort of adult, Framingham, Massachusetts, residents who, between 1948 and 1951, were assembled for a longitudinal examination of cardiovascular disease. Multivariate analyses examined the amount of residual disability attributable to stroke among 2540 community-dwelling survivors, 27 years after their initial examination, after controlling for age, cardiovascular risk factors, other cardiovascular diseases, and eight general health conditions related to physical disability. Among men living in the community, a history of stroke explained 12% of the variance in physical disability. Suffering a stroke, however, was not as strongly related to physical disability among women living in the community, accounting for only 3% of the variance. Results suggest that although older men and women die from the same major causes, they may not be disabled by the same conditions.

Hazards of obesity--the Framingham experience.

Measurements of height, weight, skinfolds and waist girth were used as indicators of general and regional obesity in the Framingham study population of 5,209 men and women. Mean values of cholesterol, blood pressure, blood glucose and uric acid increased with increasing body mass index (BMI). Weight gain was associated with increases and weight loss with decreases in these risk factors. Cigarette smoking was more prevalent in men and women with low quintile BMI. Upper quintile values of BMI, subscapular skinfolds, and waist girth were associated with increased relative risks of death from all causes, coronary heart disease (CHD) and cerebrovascular disease but relative risks for intermittent claudication were not increased. General and central obesity each made independent contributions to risk of CHD but central obesity was a better predictor in males. BMI, cholesterol, systolic blood pressure and blood glucose were significantly independent predictors of CHD. These data show that increased relative weight and central obesity are associated with elevated levels of risk factors, with increased incidence of cardiovascular disease and with increased death rates for all causes combined. Mortality rates are also increased among the leanest members of the population, especially among older men.