Serum Total Cholesterol and Long-term Coronary Heart Disease Mortality in Different Cultures: Title and subTitle BreakTwenty-five—Year Follow-up of the Seven Countries Study FREE

W. M. Monique Verschuren, MSc; David R. Jacobs, PhD; Bennie P. M. Bloemberg, PhD; Daan Kromhout, MPH, PhD; Alessandro Menotti, MD, PhD; Christ Aravanis, MD; Henry Blackburn, MD; Ratko Buzina, MD; Anastasios S. Dontas, MD; Flaminio Fidanza, MD; Martti J. Karvonen, MD, PhD; Srećko Nedelijković, MD, PhD; Aulikki Nissinen, MD, PhD; Hironori Toshima, MD

[+] Author Affiliations

Reprint requests to National Institute of Public Health and Environmental Protection, Department of Chronic Diseases and Environmental Epidemiology, PO Box 1, 3720 BA Bilthoven, the Netherlands (Ms Verschuren).

JAMA. 1995;274(2):131-136. doi:10.1001/jama.1995.03530020049031

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ABSTRACT

ABSTRACT | REFERENCES

Objective. —To compare the relationship between serum total cholesterol and long-term mortality from coronary heart disease (CHD) in different cultures.

Design. —Total cholesterol was measured at baseline (1958 through 1964) and at 5- and 10-year follow-up in 12 467 men aged 40 through 59 years in 16 cohorts located in seven countries: five European countries, the United States, and Japan. To increase statistical power six cohorts were formed, based on similarities in culture and cholesterol changes during the first 10 years of follow-up.

Main Outcome Measures. —Relative risks (RRs), estimated with Cox proportional hazards (survival) analysis, for 25-year CHD mortality for cholesterol quartiles and per 0.50-mmol/L (20-mg/dL) cholesterol increase. Adjustment was made for age, smoking, and systolic blood pressure.

Results. —The age-standardized CHD mortality rates in the six cohorts ranged from 3% to 20%. The RRs for the highest compared with the lowest cholesterol quartile ranged from 1.5 to 2.3, except for Japan's RR of 1.1. For a cholesterol level of around 5.45 mmol/L (210 mg/dL), CHD mortality rates varied from 4% to 5% in Japan and Mediterranean Southern Europe to about 15% in Northern Europe. However, the relative increase in CHD mortality due to a given cholesterol increase was similar in all cultures except Japan. Using a linear approximation, a 0.50-mmol/L (20-mg/dL) increase in total cholesterol corresponded to an increase in CHD mortality risk of 12%, which became an increase in mortality risk of 17% when adjusted for regression dilution bias.

Conclusion. —Across cultures, cholesterol is linearly related to CHD mortality, and the relative increase in CHD mortality rates with a given cholesterol increase is the same. The large difference in absolute CHD mortality rates at a given cholesterol level, however, indicates that other factors, such as diet, that are typical for cultures with a low CHD risk are also important with respect to primary prevention.(JAMA. 1995;274:131-136)

REFERENCES

ABSTRACT | REFERENCES

Keys A, ed. Coronary heart disease in seven countries. Circulation . 1970;;41( (suppl 1) ):1-211.

Keys A, Aravanis C, Blackburn H, et al. Seven Countries Study: A Multivariate Analysis of Death and Coronary Heart Disease . Cambridge, England: Harvard University Press; 1980;.

Menotti A, Keys A, Kromhout D, et al. Inte-cohort differences in coronary heart disease mortality in the 25-year follow-up of the Seven Countries Study. Eur J Epidemiol . 1993;;9:527-536.

MacMahon S, Peto R, Culter J, et al. Blood pressure, stroke, and coronary heart disease. Lancet . 1990;;335:765-774.

Keys A, Aravanis C, Blackburn H, et al. Epidemiological studies related to coronary heart disease: characteristics of men aged 40-59 in seven countries. Acta Med Scand . 1967;;460( (suppl) ):1-392.

Anderson JT, Keys A. Cholesterol in serum and lipoprotein fractions: its measurement and stability. Clin Chem . 1956;;2:145-149.

Rose GA, Blackburn H. Cardiovascular Survey Methods . Geneva, Switzerland: World Health Organization; 1968;.

International Classification of Diseases, Eighth Revision . Geneva, Switzerland: World Health Organization; 1967;.

SAS/STAT Software: Changes and Enhancements, Release 6.07 . Cary, NC: SAS Institute; 1992;. SAS technical report P-229.

Kleinbaum DG, Kupper LL, Muller KE. Applied Regression Analysis and Other Multivariable Methods . Boston, Mass: PWS-Kent Publishing Co; 1988;:265-279.

Chen Z, Peto R, Collins R, MacMahon S, Lu J, Li W. Serum cholesterol concentration and coronary heart disease in a population with low cholesterol concentrations. BMJ . 1991;;303:276-282.

Kromhout D, Bosschieter EB, Drijver M, de Lezenne Coulander C. Serum cholesterol and 25-year incidence of and mortality from myocardial infarction and cancer: the Zutphen Study. Arch Intern Med . 1988;;148:1051-1055.

Law MR, Wald NJ, Wu T, Hackshaw A, Bailey A. Systematic underestimation of association between serum cholesterol concentration and ischaemic heart disease in observational studies: data from the BUPA study. BMJ . 1994;;308:363-366.

Steinberg D, Parthasarathy S, Carew TE, Khoo JC, Witztum JL. Beyond cholesterol: modifications of low-density lipoprotein that increase its atherogenicity. N Engl J Med . 1989;;320:915-924.

Witztum JL. The oxidation hypothesis of atherosclerosis. Lancet . 1994;;344:793-795.

Reaven P, Parthasarathy S, Grasse BJ, Miller ER, Steinberg D, Witztum JL. Effects of oleaterich and linoleate-rich diets on the susceptibility of low density lipoprotein to oxidative modification in mildly hypercholesterolemic subjects. J Clin Invest . 1993;;91:668-676.

Esterbauer H, Striegl G, Puhl H, et al. The role of vitamin E and carotenoids in preventing oxidation of low density lipoproteins. Ann N YAcad Sci . 1989;;570:254-267.

Kromhout D, Keys A, Aravanis C, et al. Food consumption patterns in the 1960s in seven countries. Am J Clin Nutr . 1989;;49:889-894.

Kromhout D, Keys A, Menotti A, et al. Dietary saturated and trans-fatty acids, cholesterol and 25-year mortality from coronary heart disease: the Seven Countries Study. Prev Med . 1995;;24:308-315.

Ocke M, Kromhout D, Menotti A, et al. Average intake of antioxidant (pro)vitamins and subsequent cancer mortality in the 16 cohorts of the Seven Countries Study. Int J Cancer . 1995;;61:480-484.

Hertog MGL, Kromhout D, Keys A, et al. Flavonoid intake and risk of coronary heart disease and cancer mortality in the Seven Countries Study. Arch Intern Med . 1995;;155:381-386.

Hertog MGL, Feskens EJM, Hollman PCH, Katan MB, Kromhout D. Dietary antioxidant flavonoids and risk of coronary heart disease: the Zutphen Elderly Study. Lancet . 1993;;342:1007-1011.

de Lorgeril M, Renaud S, Mamelle N, et al. Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease. Lancet . 1994;;343:1454-1459.

Slyper AH. A fresh look at the atherogenic remnant hypothesis. Lancet . 1992;;340:289-291.

Austin M, King MC, Vranizan KM, Krauss RM. Atherogenic lipoprotein phenotype: a proposed genetic marker for coronary heart disease risk. Circulation . 1990;;82:495-506.

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