A frequently cited concept is that individual major risk factors for
coronary heart disease (CHD) are absent in many patients (perhaps >50%) with
CHD. However, prior studies have not systematically evaluated the extent to
which CHD patients have previous exposure to at least 1 risk factor, including
diabetes, cigarette smoking, or clinically elevated levels of cholesterol
or blood pressure.
To determine the frequency of exposure to major CHD risk factors.
Design, Setting, and Participants
Three prospective cohort studies were included: the Chicago Heart Association
Detection Project in Industry, with a population sample of 35 642 employed
men and women aged 18 to 59 years; screenees for the Multiple Risk Factor
Intervention Trial, including 347 978 men aged 35 to 57 years; and a
population-based sample of 3295 men and women aged 34 to 59 years from the
Framingham Heart Study (FHS). Follow-up lasted 21 to 30 years across the studies.
Main Outcome Measures
Fatal CHD in all cohorts and nonfatal myocardial infarction (MI) in
the FHS, compared by exposure to major CHD risk factors, defined as total
cholesterol of at least 240 mg/dL (≥6.22 mmol/L), systolic blood pressure
of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, cigarette
smoking, and diabetes. Participants were stratified by sex and age (18-39
vs 40-59 years).
For fatal CHD (n = 20 995), exposure to at least 1 clinically elevated
major risk factor ranged from 87% to 100%. Among those aged 40 to 59 years
at baseline with fatal CHD (n = 19 263), exposure to at least 1 major
risk factor ranged from 87% to 94%. For nonfatal MI, prior exposure was documented
in 92% (95% CI, 87%-96%) (n = 167) of men aged 40 to 59 years at baseline
and in 87% (95% CI, 80%-94%) (n = 94) of women in this age group.
Antecedent major CHD risk factor exposures were very common among those
who developed CHD, emphasizing the importance of considering all major risk
factors in determining CHD risk estimation and in attempting to prevent clinical
CHD. These results challenge claims that CHD events commonly occur in persons
without exposure to at least 1 major CHD risk factor.