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Summary
Background Although more than 80% of the global burden of cardiovascular disease occurs in low-income and
middle-income countries, knowledge of the importance of risk factors is largely derived from developed countries.
Therefore, the effect of such factors on risk of coronary heart disease in most regions of the world is unknown.
Methods We established a standardised case-control study of acute myocardial infarction in 52 countries,
representing every inhabited continent. 15 152 cases and 14 820 controls were enrolled. The relation of smoking,
history of hypertension or diabetes, waist/hip ratio, dietary patterns, physical activity, consumption of alcohol, blood
apolipoproteins (Apo), and psychosocial factors to myocardial infarction are reported here. Odds ratios and their
99% CIs for the association of risk factors to myocardial infarction and their population attributable risks (PAR) were
calculated.
Findings Smoking (odds ratio 287 for current vs never, PAR 357% for current and former vs never), raised
ApoB/ApoA1 ratio (325 for top vs lowest quintile, PAR 492% for top four quintiles vs lowest quintile), history of
hypertension (191, PAR 179%), diabetes (237, PAR 99%), abdominal obesity (112 for top vs lowest tertile and
162 for middle vs lowest tertile, PAR 201% for top two tertiles vs lowest tertile), psychosocial factors (267, PAR
325%), daily consumption of fruits and vegetables (070, PAR 137% for lack of daily consumption), regular alcohol
consumption (091, PAR 67%), and regular physical activity (086, PAR 122%), were all signicantly related to
acute myocardial infarction (p<00001 for all risk factors and p=003 for alcohol). These associations were noted in
men and women, old and young, and in all regions of the world. Collectively, these nine risk factors accounted for
90% of the PAR in men and 94% in women.
Interpretation Abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption
of fruits, vegetables, and alcohol, and regular physical activity account for most of the risk of myocardial infarction
worldwide in both sexes and at all ages in all regions. This nding suggests that approaches to prevention can be based
on similar principles worldwide and have the potential to prevent most premature cases of myocardial infarction.
Introduction
Worldwide, cardiovascular disease is estimated to be the
leading cause of death and loss of disability-adjusted life
years.1 Although age-adjusted cardiovascular death rates
have declined in several developed countries in past
decades, rates of cardiovascular disease have risen
greatly in low-income and middle-income countries,1,2
with about 80% of the burden now occurring in these
countries. Effective prevention needs a global strategy
based on knowledge of the importance of risk factors for
cardiovascular disease in different geographic regions
and among various ethnic groups.
Current knowledge about prevention of coronary heart
disease and cardiovascular disease is mainly derived from
studies done in populations of European origin.2
Researchers are unsure to what extent these ndings
apply worldwide. Some data suggest that risk factors for
coronary heart disease vary between populationseg,
lipids are not associated with this disorder in south
Asians,3 and increases in blood pressure might be more
important in Chinese people.4 Even if the association of a
www.thelancet.com Vol 364 September 11, 2004
Articles
Methods
Participants
Study participants were recruited from 262 centres from
52 countries in Asia, Europe, the Middle East, Africa,
Australia, North America, and South America (webtable 1; http://image.thelancet.com/extras/04art8001web
table1.pdf). The national coordinator selected centres
within every country on the basis of feasibility. To identify
rst cases of acute myocardial infarction, all patients
(irrespective of age) admitted to the coronary care unit or
equivalent cardiology ward, presenting within 24 h of
symptom onset, were screened. Cases were eligible if they
had characteristic symptoms plus electrocardiogram
changes indicative of a new myocardial infarction
(webappendix 1; http://image.thelancet.com/extras/
04art8001webappendix1.pdf).
At least one age-matched (up to 5 years older or
younger) and sex-matched control was recruited per
case, using specic criteria. Exclusion criteria for
controls were identical to those described for cases, with
the additional criterion that controls had no previous
diagnosis of heart disease or history of exertional chest
pain. The overall median interval from recruitment of
cases to inclusion of controls was 15 months. Hospitalbased controls (58%) were individuals who had a wide
range of disorders unrelated to known or potential risk
factors for acute myocardial infarction and were
admitted to the same hospital as the matching case.
Community-based controls (36%) were attendants or
relatives of a patient from a non-cardiac ward or an
unrelated (not rst-degree relative) attendant of a cardiac
patient. In the remaining controls, 3% were from an
undocumented source and 3% were recruited through
the WHO MONICA study.6
938
Procedures
Structured questionnaires were administered and
physical examinations were undertaken in the same
manner in cases and controls. Information about
demographic factors, socioeconomic status (education,
income), lifestyle (smoking, leisure time, physical activity,
and dietary patterns), personal and family history of
cardiovascular disease, and risk factors (hypertension,
diabetes mellitus) was obtained. Psychosocial factors
(depression, locus of control, perceived stress, and life
events) were systematically recorded and integrated into
one score: details are provided in the accompanying
paper.7 Height, weight, waist and hip circumferences, and
heart rate were determined by a standardised protocol.
Waist and hip circumferences were measured with a nonstretchable standard tape measure: waist measurements
were obtained over the unclothed abdomen at the
narrowest point between the costal margin and iliac crest,
and hip circumferences over light clothing at the level of
the widest diameter around the buttocks. Although blood
pressure at the time of examination was recorded in both
cases and controls, the levels in cases would be
systematically affected by the myocardial infarction and
treatmentseg, blockers, nitrates, and angiotensinconverting-enzyme inhibitorsthat could lower blood
pressure. Therefore, only self-reported history of
hypertension is used in the analysis.
Non-fasting blood samples (20 mL) were drawn from
every individual and centrifuged within 2 h of
admission, separated into six equal volumes, and
frozen immediately at 20C or 70C after processing.
Centres were instructed to draw blood from cases
within 24 h of symptom onset. However, because of
delays in patient presentation, especially in some lowincome countries, blood samples could only be
obtained within 24 h in two-thirds of cases. Samples
were shipped in nitrogen vapour tanks by courier from
every site to a blood storage site, where they were stored
at 160C in liquid nitrogen (Hamilton, Canada) or at
70C (India and China). Blood samples from all
countries other than China were analysed in Hamilton
for total cholesterol, HDL cholesterol, and
apolipoproteins B (ApoB) and A1 (ApoA1).
Immunoturbidimetric assays were used to measure
apolipoprotein concentrations (Roche/Hitachi 917
analyser with Tina-quant ApoB version 2 and ApoA1
version 2 kits; Roche Diagnostics, Mannheim, Germany).
The ApoB method was standardised against the IFCC
SP307 reference standard8 and the ApoA1 method
against the IFCC SP101 reference preparation.9 The
same measurement kits and a Roche/Hitachi 911
analyser were used in Beijing, China. Both laboratories
measured the same lot numbers of Precinorm and
Precipath controls (Roche Diagnostics) in every run, and
in every patient sample analysis run in China, two study
patients and two serum reference pool samples (pool A
and B) were measured that had previously been analysed
www.thelancet.com Vol 364 September 11, 2004
Articles
Statistical analysis
Simple associations were assessed with frequency tables
and Pearsons 2 tests for two independent proportions.
For comparison of prevalence across distinct
subgroupseg, by region, country, or ethnic group
potential differences in age structure of the populations
were accounted for by direct standardisation of the
frequencies to the overall INTERHEART age
distribution with a ve-level age-stratication factor
www.thelancet.com Vol 364 September 11, 2004
Articles
Panel: Formulae
where Pr(E) is probability of exposure to the risk factor and R is the relative risk of the
disease in exposed versus unexposed individuals.
where
and
X is the exposure level, C is the confounder level, and D is disease status (D=0, disease is
absent; D=1, disease is present).
Geographic region
Western Europe
Central and eastern Europe
Middle East
Africa
South Asia
China and Hong Kong
Southeast Asia and Japan
Australia and New Zealand
South America and Mexico
North America
664
1727
1639
578
1732
3030
969
589
1237
296
767
1927
1786
789
2204
3056
1199
681
1888
340
Ethnic origin
European
Chinese
South Asian
Other Asian
Arab
Latin American
Black African
Coloured African
Other
3314
3130
2171
871
1306
1141
157
311
60
3710
3167
2573
1073
1479
1834
369
339
93
Results
Between February, 1999, and March, 2003, 15 152 cases
and 14 820 controls were enrolled. 1531 cases were
diagnosed as having unstable angina, 260 had insufcient
data, 205 did not have coronary artery disease, and 695
had a previous myocardial infarction. For 74 controls data
were missing and 109 had previous coronary heart
disease. Therefore, 12 461 cases and 14 637 controls are
included in the analysis. Table 1 shows the distribution of
participants by region and ethnic origin. 9459 cases (76%)
and 10 851 controls (74%) were male.
Table 2 shows the median age of presentation of cases.
The overall median age of cases with rst acute
myocardial infarction is about 9 years lower in men than
in women in all regions of the world. However, the
proportion of male cases was highest in countries with a
younger age of presentation of acute myocardial
infarctioneg, 85% of cases in south Asia and 86% in the
Middle East were male compared with 74% in western
Europe, 68% in central and eastern Europe, and 70% in
940
Articles
Overall
Geographic region
Western Europe
Central and eastern Europe
North America
South America and Mexico
Australia and New Zealand
Middle East
Africa
South Asia
China and Hong Kong
Southeast Asia and Japan
Ethnic origin
European
Chinese
South Asian
Other Asian
Arab
Latin American
Black African
Coloured African
Other
Overall
Men
Women
Number
Number
664
1727
296
1237
589
1639
578
1732
3030
969
63 (5472)
62 (5270)
59 (5071)
60 (5170)
60 (5169)
51 (4559)
54 (4762)
53 (4661)
63 (5370)
57 (4965)
27 (18)
29 (51)
40 (12)
34 (42)
53 (31)
112 (184)
97 (56)
89 (54)
45 (135)
70 (68)
493
1173
210
926
464
1410
385
1480
2131
787
61 (5370)
59 (5068)
58 (4968)
59 (5068)
58 (5067)
50 (4457)
52 (4661)
52 (4560)
60 (5068)
55 (4764)
28 (14)
39 (46)
33 (7)
42 (39)
56 (26)
126 (177)
109 (42)
97 (143)
58 (124)
83 (65)
171
554
86
311
125
229
193
252
899
182
68 (5976)
68 (5974)
64 (5275)
65 (5673)
66 (5974)
57 (5065)
56 (4965)
60 (5066)
67 (6272)
63 (5668)
23 (4)
09 (5)
58 (5)
10 (3)
40 (5)
31 (7)
73 (14)
44 (11)
12 (11)
17 (3)
3314
3130
2171
871
1306
1141
157
311
60
12 461
62 (5271)
63 (5370)
52 (4560)
57 (4865)
53 (4660)
60 (5169)
52 (4661)
54 (4763)
57 (4864)
58 (4967)
32 (107)
44 (139)
106 (231)
70 (61)
90 (118)
37 (42)
140 (22)
87 (27)
67 (4)
60 (751)
2371
2217
1889
705
1083
854
98
196
46
9459
59 (5169)
60 (5068)
50 (4560)
55 (4764)
52 (4559)
58 (5067)
52 (4659)
52 (4662)
53 (4862)
56 (4865)
38 (89)
58 (128)
117 (220)
82 (58)
103 (111)
45 (38)
174 (17)
97 (19)
65 (3)
72 (683)
943
913
282
166
223
287
59
115
14
3002
68 (5875)
67 (6172)
60 (5166)
63 (5668)
57 (5065)
64 (5572)
54 (4867)
58 (4965)
63 (5973)
65 (5672)
19 (18)
12 (11)
39 (11)
18 (3)
31 (7)
14 (4)
85 (5)
70 (8)
71 (1)
23 (68)
287 (258319)
204 (186225)
237 (207271)
191 (174210)
112 (101125)
162 (145180)
267 (221322)
070 (062079)
086 (076097)
091 (o82102)
142 (122165)
184 (158213)
241 (209279)
325 (281376)
12920 (902418499)
357% (325391)
99% (8-5115)
179% (157204)
201% (153260)
325% (251408)
137% (99186)
122% (55251)
67% (20202)
492% (438545)
904% (881924)
2676
4812
752
2191
3340
3332
4236
1928
2445
1999
2002
1999
2000
4517
6519
1845
3902
3021
4631
3579
1427
2401
1426
1805
2422
33-49
295 (272320)
227 (211244)
308 (277342)
248 (230268)
136 (124148)
224 (206245)
251 (215293)
070 (064077)
072 (065079)
079 (073086)
147 (128168)
200 (174229)
272 (238310)
387 (339442)
12920 (902418499)
364% (339390)
123% (112135)
234% (217251)
337% (302374)
288% (226358)
129% (100166)
255% (201318)
139% (93202)
541% (496586)
904% (881924)
The median waist /hip ratio was 093 in cases and 091 in controls (p<00001), and the median ApoB/ApoA1 ratio was 085 in cases and 080 in controls (p<00001). Percentage of controls with four or ve factors positive is
222% compared with 292% in cases. *PARs for smoking, abdominal obesity, and ApoB/ApoA1 ratio are based on a comparison of all smokers vs never, top two tertiles vs lowest tertile, and top four quintiles vs lowest quintile.
For protective factors (diet, exercise, and alcohol), PARs are provided for the group without these factors. Top two tertiles vs lowest tertile. A model-dependent index combining positive exposure to depression, perceived
stress at home or work (general stress), low locus of control, and major life events, all referenced against non-exposure for all ve factors. Second, third, fourth, or fth quintiles vs lowest quintile. The model is saturated, so
adjusted and unadjusted estimates are identical for all risk factors. The odds ratio of 12920 is derived from combining all risk factors together, including current and former smoking vs never smoking, top two tertiles vs lowest
tertile of abdominal obesity, and top four quintiles vs lowest quintile of ApoB/ApoA1. If, however, the model includes only current smoking vs never smoking, the top vs lowest tertile for abdominal obesity, and the top vs lowest
quintile for ApoB/ApoA1, the odds ratio for the combined risk factors increases to 3337 (99% CI 23024839).
Table 3: Risk of acute myocardial infarction associated with risk factors in the overall population
941
Articles
16
1
Never
15
610
1115
1620
2125
2630
3140
41
727
1031
446
1058
96
230
168
56
469
1021
623
1832
254
538
459
218
138
210
299
383
580
526
634
916
1
075
1
10
Figure 1: Odds of myocardial infarction according to number of cigarettes smoked and ApoB/ApoA1 ratio
Note the doubling scale on the y axis for both gures.
423 (332540), and the PAR for these four risk factors
together (top four quintiles of ApoB/ApoA1 ratio vs lowest
quintile) was 758% (99% CI 727786). Addition of
abdominal obesity (top two tertiles vs lowest tertile)
further increased the PAR to 802% (775827).
Figure 3 shows the effects of multiple risk factors on
reduced risk of acute myocardial infarction associated
with healthy lifestyles. Daily consumption of fruit and
vegetables and regular physical activity conferred an
odds ratio of 060 (99% CI 051071). Further, if an
individual avoided smoking, the odds ratio would be
021 (017025; gure 3), suggesting that
modication of these aspects of lifestyle could
potentially reduce the risk of an acute myocardial
infarction by more than three-quarters compared with a
smoker with a poor lifestyle.
Incorporation of all nine independent risk factors
(current or former smoking, history of diabetes or
942
hypertension, abdominal obesity, combined psychosocial stressors, irregular consumption of fruits and
vegetables, no alcohol intake, avoidance of any regular
exercise, and raised plasma lipids) indicates an odds
ratio of 12920 (99% CI 902418499; table 3),
compared with not having any of these risk factors.
Substituting the odds ratios for current smoking, the
extremes of abdominal obesity (top vs lowest tertile) and
ApoB/ApoA1 ratio (top vs lowest quintile) increases the
combined effect of all nine risk factors to 3337 (99% CI
23024839; gure 2). This represents a PAR of 904%
(99% CI 881924), suggesting that these risk factors
account for most of the risk of acute myocardial
infarction in our study population. In view of the overlap
in the effect of the nine risk factors, most of the PAR
could be accounted for by a combination of various risk
factors, as long as they included smoking and the
ApoB/ApoA1 ratio (PAR for their combination is 668%
[99% CI 628706]). The estimate of the combined
effect of all nine risk factors is derived from a model,
since very few individuals had zero risk factors or all
nine risk factors. However, condence that the majority
of risk is indeed accounted for by these risk factors is
lent support by the fact that of the 18 708 individuals
with complete data on all risk factors, 43 controls and
24 cases had no risk factors and 49 cases and 11 controls
had eight or more. Also, just ve risk factors (smoking,
lipids, hypertension, diabetes, and obesity), which a
large proportion of individuals had, accounted for about
80% of the PAR.
Articles
Risk by age
24
19
29
(2632) (2127) (1721)
256
128
64
32
16
8
4
2
1
Smk
(1)
DM
(2)
HTN
(3)
ApoB/A1
(4)
1+2+3
All 4
+Obes
+PS
All RFs
Figure 2: Risk of acute myocardial infarction associated with exposure to multiple risk factors
Smk=smoking. DM=diabetes mellitus. HTN=hypertension. Obes=abdominal obesity. PS=psychosocial. RF=risk
factors. Note the doubling scale on the y axis. The odds ratios are based on current vs never smoking, top vs lowest
tertile for abdominal obesity, and top vs lowest quintile for ApoB/ApoA1. If these three are substituted by current
and former smoking, top two tertiles for abdominal obesity and top four quintiles for ApoB/ApoA1, then the odds
ratio for the combined risk factor is 12920 (99% CI 902418499).
070
035
(031039) (062079)
10
1829
3337
33
130
423
685
(2838) (107158) (332540) (530886) (13262522) (23024839)
512
086
(076097)
091
(082102)
024
(021029)
021
(017025)
019
(015024)
05
025
0125
00625
No
Smk
Fr/vg
Exer
Alc
No Smk
+Fr/Vg
+Ex
+Alc
Figure 3: Reduced risk of acute myocardial infarction associated with various risk factors
Smk=smoking. Fr/vg=fruits and vegetables. Exer=exercise. Alc=alcohol. Note the doubling scale on the y axis. Odds
ratios are adjusted for all risk factors.
943
Articles
Risk factor
Sex
Current smoking F
93
201
286 (236348)
158% (129193)
330
531
305 (278333)
440% (409472)
Diabetes
79
255
426 (351518)
191% (168217)
74
162
267 (236302)
101% ( 89114)
Hypertension
283
530
295 (257339)
358% (321396)
197
346
232 (212253)
195% (177215)
Abdominal
obesity
333
456
226 (190268)
359% (289436)
333
465
224 (203247)
321% (280365)
Psychosocial
index
349 (241504)
400% (286526)
258 (211314)
253% (182340)
Fruits/veg
503
394
058 (048071)
178% (129241)
396
347
074 (066083)
103% ( 69152)
Exercise
165
93
048 (039059)
373% (261500)
203
158
077 (069085)
229% (169302)
Alcohol
112
63
041 (032053)
469% (343600)
291
296
088 (081096)
105% (61175)
141
270
442 (343570)
521% (440602)
219
355
376 (323438)
538% (483592)
ApoB/ApoA1
ratio
025
05
16
Figure 4: Association of risk factors with acute myocardial infarction in men and women after adjustment for age, sex, and geographic region
For this and subsequent gures, the odds ratios are plotted on a doubling scale. Prevalence cannot be calculated for psychosocial factors because it is derived from a
model.
Consistency of results
Subgroup analyses with both types of controls (hospitalbased and community-based) showed consistent odds
ratios for current smoking (hospital-based 31 vs
community-based 28), for the top quintile versus lowest
quintile of lipids (42 vs 39), for diabetes (27 vs 34),
for hypertension (21 vs 30), for abdominal obesity (17
vs 19), for psychosocial factors (16 vs 15), for
consumption of fruits (078 vs 093) and vegetables
(078 vs 083), for regular physical activity (079 vs 079),
and for alcohol use (079 vs 086).
583 cases of acute myocardial infarction subsequently
died in hospital. Odds ratios for fatal myocardial
infarction associated with various risk factors were
similar to those overallsmoking (21 for fatal
myocardial infarction vs 30 overall), diabetes (40 vs
31), hypertension (24 vs 25), abdominal obesity (15
vs 22), and lipids (26 vs 39).
Family history
Family history of coronary heart disease was associated
with an odds ratio of 155 (99% CI 144167),
adjusted for age, sex, smoking, and geographic region.
Adjustments for the nine previously described risk
factors slightly reduced the odds ratio to 145
(131160). The PAR was 120% (99% CI
944
Repeat measures
Repeat measures of risk factors were made in 279 controls
at a median interval of 409 days. The agreement rates for
smoking (Cohens kappa16 =094), history of diabetes
(=090), ApoB/ApoA1 (intraclass correlation=074),
hypertension (=082), depression (=044), abdominal
obesity (intraclass correlation=068), regular physical
activity (=056), and consumption of fruits (=066),
vegetables (=052), and alcohol (=052) were high to
moderate. These data suggest that the association of
myocardial infarction with smoking and diabetes is closer
to the real effect, whereas the association of other risk
factors measured with greater variability are probably
underestimates due to regression-dilution bias.17
www.thelancet.com Vol 364 September 11, 2004
Articles
Region
Men
Western Europe
Central and eastern Europe
Middle East
Africa
South Asia
China
Southeast Asia and Japan
Australia and New Zealand
South America
North America
Overall 1
Overall 2
Women
West Europe
Central and eastern Europe
Middle East
Africa
South Asia
China
Southeast Asia and Japan
Australia and New Zealand
South America
North America
Overall 1
Overall 2
Men and women
West Europe
Central and eastern Europe
Middle East
Africa
South Asia
China
Southeast Asia and Japan
Australia and New Zealand
South America
North America
Overall 1
Overall 2
Lifestyle factors
Lipids (%)
390
404
514
452
420
453
392
461
424
309
440
427
133
76
58
44
160
151
85
80
71
224
103
117
377
04
19
159
255
166
314
206
276
247
229
93
141
104
27
241
57
42
246
112
74
66
105
51
696
489
507
637
581
637
696
610
577
539
638
565
205
159
58
268
178
199
343
183
281
139
195
149
128
58
131
116
105
79
191
56
97
61
101
80
686
317
239
604
360
49
579
495
352
647
321
197
237
09
372
338
139
320
269
316
361
637
253
288
367
387
727
737
602
413
687
487
416
600
538
495
920
719
948
979
884
888
937
875
861
100
898*
898*
111
131
81
276
71
125
148
407
258
253
158
148
84
128
159
210
306
236
199
158
59
128
178
191
383
427
391
379
450
335
328
336
274
272
373
271
342
299
590
288
260
358
695
474
441
733
469
221
652
654
803
612
598
786
845
800
718
869
750
606
259
427
301
351
289
276
563
370
479
302
358
290
210
157
303
275
205
150
292
117
222
124
191
161
506
200
389
546
487
63
580
672
630
445
359
187
671
150
774
549
292
432
270
172
378
327
400
452
479
268
633
746
521
483
645
149
593
322
521
471
971
861
994
933
993
936
965
961
941*
941*
293
302
455
389
374
359
362
448
383
261
364
357
124
102
73
48
183
180
112
111
66
198
129
137
384
113
42
101
271
203
314
238
276
256
255
122
187
129
10
266
55
57
279
186
37
255
139
67
676
496
476
634
566
623
699
660
566
599
629
546
219
245
92
296
193
221
384
226
327
190
234
179
150
91
155
167
118
100
210
72
127
80
123
99
634
280
259
584
377
55
580
613
455
595
337
201
389
49
416
400
159
354
267
289
356
514
288
325
446
350
705
741
587
438
677
434
476
505
541
492
939
725
950
974
894
899
937
895
894
987
904*
904*
PAR estimates in women in some countries are based on small numbers and so they are less reliable . Overall 1= adjusted for age, sex, and smoking, Overall 2=adjusted for all risk factors. An extended version of this table with
99% CIs is shown in webtable 3 (http://image.thelancet.com/extras/04art8001webtable3.pdf). *Saturated model, no difference between adjusted and unadjusted models. Non-estimatable.
Table 4: PARs associated with nine risk factors in men and women by geographic region
Discussion
Our study shows that nine easily measured and
potentially modiable risk factors account for an
overwhelmingly large (over 90%) proportion of the risk
of an initial acute myocardial infarction. The effect of
these risk factors is consistent in men and women,
across different geographic regions, and by ethnic
group, making the study applicable worldwide. The
effect of the risk factors is particularly striking in young
men (PAR about 93%) and women (about 96%),
indicating that most premature myocardial infarction is
preventable. Worldwide, the two most important risk
factors are smoking and abnormal lipids. Together they
account for about two-thirds of the PAR of an acute
myocardial infarction. Psychosocial factors, abdominal
obesity, diabetes, and hypertension were the next most
important risk factors in men and women, but their
www.thelancet.com Vol 364 September 11, 2004
Articles
Both sexes
Men
Young
Odds ratios for relative effect of risk factors (99% Cl)
Lifestyle factors
Smoking
333 (286387)
Fruit and vegetables
069 (058081)
Exercise
095 (079114)
Alcohol
100 (085117)
All four lifestyle factors
020 (014027)
Hypertension
224 (193260)
Diabetes
296 (240364)
Abdominal obesity
179 (152209)
Psychosocial
287 (219377)
High ApoB/ApoA1 ratio
435 (349542)
All risk factors other than smoking
10186 (612216946)
All nine risk factors including smoking
21647 (1266736994)
Population attributable risks (99% CI)
Lifestyle factors
Smoking
407% (359 to 457)
Fruit and vegetables
169% (108 to 253)
Exercise
75% (07to 469)
Alcohol
41% (198 to 116)
All four lifestyle factors
52.1% (395 to 644)
Hypertension
192% (160 to 228)
Diabetes
124% (103 to 149)
Abdominal obesity
248% (172 to 345)
Psychosocial
435% (322 to 556)
High ApoB/ApoA1 ratio
589% (509 to 665)
All risk factors other than smoking
894% (847 to 927)
All nine risk factors including smoking
938% (909 to 958)
Women
55 years
>55 years
65 years
244* (210284)
333 (280395)
072 (061085)
072 (0590.88)
079 (066094)
102 (083125)
085 (073100)
103 (087123)
020 (015027)
023 (016033)
172 (152195)
199 (166239)
205* (171245)
266 (204346)
150 (129174)
183 (152220)
243 (186318)
262 (191360)
250* (205305)
416 (319542)
4324* (26966937)
5906 (322510814)
8199* (500213440) 12919 (686024328)
252 (215296)
077 (064093)
079 (066096)
086 (0731.01)
021 (0150.29)
172 (149198)
193 (158237)
154 (130183)
245 (182329)
251 (200315)
3888 (22956586)
7625 (440713193)
449 (311647)
214 (135339)
062 (044087)
055 (038080)
074 (049110)
075 (046122)
074 (041131)
083 (049142)
007 (003018)
016 (006041)
294 (225385)
182 (139238)
353 (249501)
259 (178378)
158 (114220)
122 (088170)
392 (226679)
231 (122439)
483 (319732)
248 (160383)
47343 (1583414155) 6749 (213921290)
11006 (3427235342) 11145 (325938112)
Old
> 65 years
*p<0001 are only provided for the overall comparison. These values differ slightly but appear similar because of rounding. Based on combining current and former smokers vs never smokers, top two tertiles vs lowest tertile
for abdominal obesity, and top four quintiles vs lowest quintile for ApoB/ApoA1 ratio. If, however, extreme exposures (current vs never, top vs lowest tertile for abdominal obesity, and top vs lowest quintile for ApoB/ApoA1
ratio) were included, the odds ratios for all risk factors for the young group increases to 7560 and in the old group to 1608. Unstable estimate, should be interpreted cautiously.
Region
Overall
26 527
479
364% (339390)
656
227 (211244)
W Eur
1403
550
733
196 (147262)
293% (178441)
CE Eur
3624
542
698
192 (160230)
302% (230386)
MEC
3301
454
645
264 (219319)
455% (393519)
Afr
1339
538
701
218 (160296)
389% (271522)
S Asia
3706
410
603
243 (203289)
374% (316436)
China/HK
6062
427
622
230 (200265)
359% (315405)
SE Asia
2131
571
705
196 (154249)
360% (259475)
ANZ
1267
542
774
280 (203386)
448% (330572)
S Am
3068
489
694
235 (192287)
383% (310461)
N Am
626
646
768
182 (114288)
261% (88565)
025
05
16
Figure 5: Risk of acute myocardial infarction associated with current or former smoking, overall and by region after adjustment for age and sex
W Eur=western Europe. CE Eur=central and eastern Europe. MEC=Middle East Crescent. Afr=Africa. S=South. HK=Hong Kong. SE=southeast. ANZ=Australia and New
Zealand. N=North. Am=America.
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Region
Overall
21 408
200
335
387 (339442)
541% (496586)
W Eur
1047
138
294
376 (210674)
446% (235678)
CE Eur
2618
203
294
220 (152318)
350% (192549)
MEC
3291
299
496
533 (348818)
705% (578807)
Afr
1037
180
390
793 (4321458)
741% (597846)
S Asia
2820
277
427
381 (249583)
587% (427731)
China/HK
5400
73
143
343 (261451)
438% (367512)
SE Asia
1858
227
480
622 (3711041)
677% (520802)
ANZ
487
138
268
397 (171922)
434% (160756)
S Am
2644
271
406
279 (185423)
476% (296662)
N Am
206
124
288
475 (1341686)
505% (182824)
025
05
16
Figure 6: Risk of acute myocardial infarction associated with ApoB/ApoA1 ratio (top vs lowest quintile), overall and by region after adjustment for age, sex,
and smoking
PAR is for the top four quintiles versus the lowest quintile.
Our data show that risks associated with the major risk
factors (odds ratio of about 2 or greater on univariate
analyses, such as smoking, abnormal lipids,
psychosocial factors, hypertension, diabetes, and
abdominal obesity) were consistently adverse in all
regions of the world and in all ethnic groups. In
particular, the odds ratios for these risk factors were
qualitatively similar (although some quantitative
differences were apparent), despite variations in
prevalence for every risk factor in controls derived from
different subpopulations. However, as expected, the
PAR is affected both by the prevalence of the risk factor
and the odds ratio. We are unaware of any other large
study that has assessed whether risk factors have a
similar or differing effect in many ethnic groups.
Region
Overall
26 916
223
386
248 (230268)
234% (217251)
W Eur
1425
164
330
222 (162305)
219% (156300)
CE Eur
3636
327
460
211 (176253)
245% (192306)
MEC
3404
202
259
184 (145233)
92% (57144)
Afr
1355
216
434
334 (240465)
296% (228373)
S Asia
3881
138
311
289 (231360)
193% (157234)
China/HK
6075
211
373
241 (206280)
221% (187260)
SE Asia
2141
153
468
563 (426745)
384% (333436)
ANZ
1269
220
378
194 (140268)
226% (156316)
S Am
3100
277
493
248 (203304)
327% (272388)
N Am
630
286
388
158(101247)
190% (92352)
025
05
16
Figure 7: Risk of acute myocardial infarction associated with self-reported hypertension, overall and by region after adjustment for age, sex, and smoking
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Region
Overall
26 903
76
183
308 (277342)
123% (112135)
W Eur
1422
42
177
429 (261705)
150% (110201)
CE Eur
3636
68
138
261 (195349)
91% (66124)
MEC
3401
116
251
292 (226379)
155% (122194)
Afr
1355
80
250
369 (238573)
167% (118231)
S Asia
3882
106
214
248 (193318)
118% (89155)
China/HK
6075
29
116
507 (372690)
100% (83119)
SE Asia
2140
92
274
419 (301583)
210% (168259)
72% (39128)
ANZ
1269
48
118
237 (134419)
S Am
3093
90
202
245 (186324)
127% (94170)
N Am
630
97
166
175 (094329)
80% (29201)
025
05
16
Figure 8: Risk of acute myocardial infarction associated with self-reported diabetes, overall and by region after adjusting for age, sex, and smoking
Region
Overall
26 136
342
472
224 (206245)
337% (302374)
W Eur
1306
341
625
450 (298678)
634% (513741)
CE Eur
3538
410
493
174 (139217)
280% (183403)
MEC
3309
451
582
185 (143241)
259% (137435)
Afr
1265
388
611
375 ( 244574)
584% (441713)
S Asia
3821
312
442
243 (193306)
377% (288474)
China/HK
6018
211
253
132 (111158)
55% (14194)
SE Asia
2101
211
444
571 (413789)
579% (491662)
ANZ
1224
392
638
440 (282688)
613% (456749)
S Am
2959
486
648
241 (179325)
455% (323592)
N Am
595
313
637
468 (257850)
595% (403762)
025
05
16
Figure 9: Risk of acute myocardial infarction associated with abdominal obesity measured as waist/hip ratio (upper tertile vs lowest tertile), overall and by
region after adjusting for age, sex, and smoking
PARs are for top two tertiles vs lowest tertile.
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Region
Overall
24 767
251 (215293)
288% (226358)
389% (202615)
W Eur
1375
392 (195791)
CE Eur
3473
114 (073178)
49% (00960)
MEC
2892
277 (178429)
416% (252601)
Africa
1259
317 (159633)
400% (173679)
S Asia
3300
215 (145317)
159% (40463)
China/HK
5894
600 (405889)
354% (246479)
267% (178381)
SE Asia
1921
185 (102337)
ANZ
1255
199 (102387)
289% (100597)
S Am
2783
208 (129336)
356% (172595)
N Am
615
416 (1501153)
514% (240780)
025
05
16
Figure 10: Risk of acute myocardial infarction associated with the composite psychosocial index, overall and by region
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