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Copyright © 2000 by The Johns Hopkins University School of Hygiene and Public Health Printed in U.S.A.
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Herman A. Tyroler
FIGURE 1. Multilevel, interacting determinants of levels of and trends in coronary heart disease in populations.
ment, admission of less severe cases, or more favor- system, which offers preventive and therapeutic treat-
able risk factor profiles of cases is unclear (7-9). ments in and out of hospital, is becoming an increas-
There has been differential use of diagnostic, ingly important environmental determinant of the dis-
medical, and surgical procedures such as angiogra- tribution of CHD in populations.
phy, thrombolytic therapy, and coronary artery
bypass surgery in relation to ethnicity, socio- SUBCLINICAL ATHEROSCLEROSIS
economic status, and gender; these procedures are
used less frequently for women and in minority and Despite its marked increase with age, and in contrast
socioeconomically disadvantaged strata of the US to earlier beliefs, atherosclerosis resulting in CHD is
population (10). Additionally, use of simple adjunc- not a degenerative, inevitable consequence of aging.
tive medication such as aspirin and beta blockers of Atherosclerosis begins early in life, and it results from
proven efficacy in clinical trials, during and after endothelium injury and repair as well as from active
acute ischemic episodes, varies across regions of the subintimal inflammatory, immunologic, metabolic,
United States (11). Furthermore, there are complex and hemostatic processes involving multiple systems
interactive associations of CHD severity, treatment, and cell types (13). It progresses in stages from depo-
and prognosis with supraindividual group and popu- sition of hpid-laden macrophages (foam cells) to fatty
lation characteristics. streaks and fibrous plaques with lipid core and calcium
Improved in-hospital survival of acute ischemic deposits; complicated lesions result from endothelium
episodes can be expected to increase the prevalence in disruption, hemorrhage, and occlusive thrombosis (14,
populations of persons more susceptible to recurrent 15). Autopsy studies disclose geographic variation in
episodes and chronic cardiovascular disease complica- atherosclerosis prevalence and severity associated
tions such as congestive heart failure. Regardless of with population mortality rates and association of ath-
extent, reduced hospital mortality cannot prevent most erosclerosis with the established risk factors, even at
CHD deaths, since the majority (approximately 60 per- young ages (16). Many of the pathologic cellular, his-
cent of all deaths attributed to CHD) occur out of hos- tologic, gross structural, and functional changes in
pital. It is difficult to obtain valid estimates of the lev- arteries can now be assessed in population studies by
els of and trends in sudden CHD deaths in and out of measuring circulating markers of cell biology
hospital; however, available US data indicate increas- processes and by using noninvasive imaging and func-
ing inequalities in relation to the socioeconomic status tional techniques.
of persons and the social environment of populations Results of ultrasound imaging of superficial arteries,
(12). Thus, organization and use of the medical care such as the carotids, presently serve as a marker of sys-
Epidemiol Rev Vol. 22, No. 1, 2000
Coronary Heart Disease in the 21st Century 9
temic atherosclerosis. Carotid intima-media wall of incident disease. The CHD risk for women and men
thickness provides reliable and valid estimates of the whose scores are in the upper quintile is 10-20 times
presence and extent of local atherosclerosis, is corre- higher than for those whose scores are in the lowest
lated with angiographic coronary atherosclerosis, is quintile (25). The major risk factors are similarly pre-
related to the established risk factors, and predicts dictive of CHD for men and women (26) and appear so
prevalent and incident CHD (17, 18). Thickness of this for minorities (27, 28). Although extensive quantita-
wall also varies strongly and inversely with socioeco- tive data currently are lacking for groups other than
nomic status (19). Indices of atherosclerosis in the White men, large-scale observational studies and clin-
arterial beds supplying the lower extremities are ical trials are under way for women. (29). Life-course
obtained from the ratio of ankle to brachial artery study indicates tracking of risk factor levels over time
blood pressure. This index also is related to the estab- (30), and levels are associated with subclinical athero-
lished CHD risk factors and to prevalent CHD (20). sclerosis in adolescents and young adults (16).
More direct epidemiologic assessment of the coronary Risk summary scores based on the established risk
arteries may be provided by quantitative radiologic factors in one population rank order CHD risk for per-
estimation of calcium deposition. Coronary calcium sons in other populations with different CHD rates, but
scores predict the extent of angiographic disease and they usually do not predict absolute incidence rates
CHD case prognosis and are correlated with estab- across socially diverse populations. The aggregate
lies does not totally account for the within-family port, social isolation, job instability, and powerless-
aggregation of CHD. Furthermore, occurrence of CHD ness, with CHD have variously been summarized as
in families usually does not follow the pattern of sim- inadequate, conflicting, or inconclusive for women
ple Mendelian inheritance, leading to the aphorism (46) and conversely as strong enough to enable clinical
that CHD aggregates but does not segregate within trials to be undertaken of the efficacy of modifying
families. Inheritance of increased susceptibility to some of these factors (47, 48). In contrast, strong, con-
CHD results from the intergenerational transmission of sistent evidence exists of the association of CHD risk
cultural, lifestyle, and shared environmental determi- behavior, risk factors, subclinical atherosclerosis, and
nants of CHD (40) as well as multiple susceptibility clinically manifest CHD with individual socioeco-
genes. Parental socioeconomic status is a strong deter- nomic status (49). Levels of and long-term trends in
minant of the adult socioeconomic status of offspring, CHD also vary according to the social environmental
and CHD-relevant lifestyle, behavioral, dietary, and characteristics of nations and of geopolitical units
smoking practices may thereby aggregate within fam- within nations (50). CHD mortality rates increased dur-
ilies and be expressed as adult CHD risk (41, 42). ing the transition of rural, agrarian, and economically
A large number of genes associated with increased risk underdeveloped societies to urbanized, industrialized,
of CHD have been identified, generally by their relation and modernized societies. Socioeconomic status was
to the known risk factors. For example, numerous bio- related positively to CHD during the ascending limb of
trends in CHD is illustrated by the failure to predict, or life. Modifying a person's CHD risk with lifestyle
even in retrospect to explain adequately, the onset of interventions and medical treatments will be more effi-
the decline of CHD mortality rates in the United States cacious and potentially more effective. Continuing
and most western industrialized nations in the 1960s. advances in treatment of ischemic episodes will result
To date, controversy remains regarding the relative in increasing survival and decreased morbidity but with
contribution of decreasing incidence and decreasing consequent increases in prevalence of the disease.
case fatality to the subsequent decline in CHD mortal- Study of the emerging risk factors will increase knowl-
ity in these countries (55, 56). The failure to predict edge about mechanisms responsible for atherosclerosis
trends in CHD risk-related factors also is illustrated by and its clinical complications. Technologic innovations,
the unanticipated current worldwide increase in obe- which permit noninvasive assessment of the structure
sity. In addition, mortality differences are widening and function of the coronary arteries and heart in pop-
among ethnic and socioeconomic groups in the United ulation studies, combined with methodological and
States, and recent trend analyses suggest flattening of analytical advances in information processing, will
the CHD decline for the aggregate population despite enable extended epidemiologic investigations of all
increasing epidemiologic knowledge, educational pro- stages from clinical CHD and subclinical coronary ath-
grams, and public health and medical care efforts. erosclerosis to risk factors and their determinants
Similar uncertainty exists about the causes of the beginning early and continuing over a person's life.
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