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1.  Cardiovascular disease incidence and mortality in older men with diabetes and in men with coronary heart disease 
Heart  2004;90(12):1398-1403.
Objective: To examine the relation of diabetes and coronary heart disease (CHD; myocardial infarction (MI) or angina) to the incidence of major CHD and stroke events and total mortality.
Methods: Prospective study of 5934 men aged 52–74 years followed up for 10 years. The men were divided into five groups according to their diabetes and CHD status.
Results: During the follow up there were 662 major CHD events, 305 major stroke events, and 1357 deaths from all causes (637 cardiovascular disease (CVD) deaths, 417 CHD deaths). Men with diabetes had significantly increased cardiovascular and total mortality risk compared with non-diabetic men with no CHD but lower risk than men with prior MI only. The adjusted relative risk for CHD deaths was 2.82 (95% confidence interval (CI) 1.85 to 4.28) in men with diabetes only, 2.12 (95% CI 1.53 to 2.93) in men with angina only, 3.91 (95% CI 3.07 to 4.99) in men with MI, and 8.93 (95% CI 6.13 to 12.99) in men with both diabetes and CHD. Case fatality among men with diabetes only was similar to those with prior MI only. CHD and CVD mortality increased with increasing duration of diabetes with risk eventually approaching that of patients with MI without diabetes.
Conclusion: Men with diabetes only have a CVD risk intermediate between men with angina and men with prior MI. Their absolute risk is high and the prognosis for diabetic patients who develop CHD is extremely poor.
doi:10.1136/hrt.2003.026104
PMCID: PMC1768570  PMID: 15547012
non-insulin dependent diabetes mellitus; myocardial infarction; cardiovascular disease; mortality
2.  Taking up regular drinking in middle age: effect on major coronary heart disease events and mortality 
Heart  2002;87(1):32-36.
Aim: To examine effects of taking up regular drinking by middle aged non-drinkers and occasional drinkers on major coronary heart disease events and total mortality.
Methods: A prospective study of 7735 men from general practices in 24 British towns screened in 1978–80 at age 40–59 years (Q1). Five years after screening, 7157 men then aged 45–64 completed postal questionnaires (Q5) on changes in alcohol intake.
Results: In 6503 men without diagnosed coronary heart disease, there were 874 major coronary heart disease events and 1613 total deaths during 16.8 years of follow up after Q5. With stable occasional drinkers as baseline, men who continued to drink regularly had a significantly lower risk of major coronary heart disease events, coronary heart disease mortality, and overall cardiovascular mortality, but a slightly increased risk of non-cardiovascular mortality. New regular drinkers (89% light), even after adjustment for their many advantageous characteristics, showed a lower risk of major coronary heart disease events than stable occasional drinkers (relative risk (RR) = 0.70; 95% confidence interval (CI) 0.48 to 1.03; p = 0.07). New drinkers showed no reduction in coronary heart disease or cardiovascular mortality and experienced an increase in risk of non-cardiovascular mortality (RR = 1.40; 95% CI 0.99 to 1.97; p = 0.06). In 654 men with diagnosed coronary heart disease, new drinkers experienced no mortality benefit compared with stable occasional drinkers.
Conclusions: Middle aged new regular drinkers experienced lower risk of major coronary heart disease events than stable occasional drinkers or non-drinkers, but had increased risk of non-cardiovascular mortality and total mortality. These findings provide little support for encouraging older men who do not drink or who only drink occasionally to take up regular drinking, whether or not they have coronary heart disease.
PMCID: PMC1766954  PMID: 11751661
alcohol; drinking; coronary heart disease; mortality
3.  Physical activity and risk of cancer in middle-aged men 
British Journal of Cancer  2001;85(9):1311-1316.
A prospective study was carried out to examine the relationship between physical activity and incidence of cancers in 7588 men aged 40–59 years with full data on physical activity and without cancer at screening. Physical activity at screening was classified as none/occasional, light, moderate, moderately-vigorous or vigorous. Cancer incidence data were obtained from death certificates, the national Cancer Registration Scheme and self-reporting on follow-up questionnaires of doctor-diagnosed cancer. Cancer (excluding skin cancers) developed in 969 men during mean follow-up of 18.8 years. After adjustment for age, smoking, body mass index, alcohol intake and social class, the risk of total cancers was significantly reduced only in men reporting moderately-vigorous or vigorous activity; no benefit seen at lesser levels. Sporting activity was essential to achieve significant benefit and was associated with a significant dose-response reduction in risk of prostate cancer and upper digestive and stomach cancer. Sporting (vigorous) activity was associated with a significant increase in bladder cancer. No association was seen with colo-rectal cancer. Non-sporting recreational activity showed no association with cancer. Physical activity in middle-aged men is associated with reduced risk of total cancers, prostate cancer, upper digestive and stomach cancer. Moderately-vigorous or vigorous levels involving sporting activities are required to achieve such benefit.   http://www.bjcancer.com © 2001 Cancer Research Campaign
doi:10.1054/bjoc.2001.2096
PMCID: PMC2375260  PMID: 11720466
physical activity; cancer
4.  Serum urate and the risk of major coronary heart disease events. 
Heart  1997;78(2):147-153.
OBJECTIVE: To examine the relation between serum urate and the risk of major coronary heart disease events. DESIGN: A prospective study of a male cohort. SETTING: One general practice in each of 24 British towns. SUBJECTS: 7688 men aged 40-59 years at screening. MAIN OUTCOME MEASURES: Fatal and non-fatal coronary heart disease events. RESULTS: There were 1085 major coronary heart disease events during the average follow up period of 16.8 years. Serum urate was significantly associated with a wide range of cardiovascular risk factors including body mass index, alcohol intake, antihypertensive treatment, pre-existing coronary heart disease, serum triglycerides, cholesterol, and diastolic blood pressure. There was a significant positive association between serum urate and risk of coronary heart disease after adjustment for lifestyle factors and disease indicators. This relation was attenuated to non-significance upon additional adjustment for diastolic blood pressure and serum total cholesterol: cholesterol appeared to be the critical factor in attenuating this relation. When the association between serum urate and risk of coronary heart disease was examined by presence and grade of pre-existing coronary heart disease, a positive association was seen only in men with previous definite myocardial infarction, even after full adjustment (P = 0.07). CONCLUSIONS: The relation between serum urate and the risk of coronary heart disease depends heavily upon the presence of pre-existing myocardial infarction and widespread underlying atherosclerosis as well as the clustering of risk factors. Thus serum urate is not a truly independent risk factor for coronary heart disease. Raised serum urate appears to be an integral part of the cluster of risk factors associated with the insulin resistance syndrome that include obesity, raised serum triglycerides, and serum cholesterol.
PMCID: PMC484894  PMID: 9326988
5.  Cigarette smoking in British men and selection for coronary artery bypass surgery. 
Heart  1996;75(6):557-562.
OBJECTIVE: To examine the relation between smoking status, clinical need, and likelihood of coronary artery bypass grafting in middle aged men. DESIGN: A prospective study of cardiovascular disease in British men aged 40 to 59 years, screened in 1978-80 and followed until December 1991. SUBJECTS AND SETTING: 7735 men drawn from one general practice in each of 24 British towns. MAIN OUTCOME MEASURE: Coronary artery bypass graft surgery. RESULTS: Of the 3185 current smokers, 38 (1.03/1000/year) underwent coronary artery bypass surgery compared with 47 of 2715 (1.45/1000/year) ex-smokers, and 19 of 1817 (0.85/1000/year) never-smokers. Ex-smokers had a lower incidence of major ischaemic heart disease during follow up than current smokers. After adjustment for incidence of ischaemic heart disease during follow up, the hazard ratio of coronary artery bypass surgery for ex-smokers compared with smokers was 1.52 (95% confidence interval 0.99 to 2.34). Ex-smokers were more likely at screening to recall a doctor diagnosis of ischaemic heart disease than smokers (7.1% v 5.3%), but among those who recalled a doctor diagnosis, smokers were less likely to undergo coronary artery bypass surgery than ex-smokers (9.4% v 3.5%, P = 0.026). By 1992, men defined as smokers at screening were no less likely than ex-smokers to have been referred to a cardiologist (18.5% v 18.8%), nor to report having undergone coronary angiography less frequently than ex-smokers (12.7% v 11.4%). CONCLUSION: Even allowing for the strong relation between coronary artery bypass surgery and clinical need, continuing smokers were less likely to undergo coronary artery bypass surgery than ex-smokers. A complex interplay exists between the men's experience of heart disease, the decision to stop smoking, and the willingness of doctors to consider coronary artery bypass surgery.
PMCID: PMC484376  PMID: 8697156
6.  Body weight: implications for the prevention of coronary heart disease, stroke, and diabetes mellitus in a cohort study of middle aged men. 
BMJ : British Medical Journal  1997;314(7090):1311-1317.
OBJECTIVE: To determine the body mass index associated with the lowest morbidity and mortality. DESIGN: Prospective study of a male cohort. SETTING: One general practice in each of 24 British towns. SUBJECTS: 7735 men aged 40-59 years at screening. MAIN OUTCOME MEASURES: All cause death rate, heart attacks, and stroke (fatal and non-fatal) and development of diabetes, or any of these outcomes (combined end point) over an average follow up of 14.8 years. RESULTS: There were 1271 deaths from all causes, 974 heart attacks, 290 strokes, and 245 new cases of diabetes mellitus. All cause mortality was increased only in men with a body mass index (kg/m2) < 20 and in men with an index > or = 30. However, risk of cardiovascular death, heart attack, and diabetes increased progressively from an index of < 20 even after age, smoking, social class, alcohol consumption, and physical activity were adjusted for. For the combined end point the lowest risks were seen for an index of 20.0-23.9. In never smokers and former smokers, deaths from any cause rose progressively from an index of 20.0-21.9 and for the combined end point, from 20.0-23.9. Age adjusted levels of a wide range of cardiovascular risk factors rose or fell progressively from an index < 20. CONCLUSION: A healthy body mass index in these middle aged British men seems to be about 22.
PMCID: PMC2126570  PMID: 9158466
7.  Factors determining case fatality in myocardial infarction "who dies in a heart attack"? 
British Heart Journal  1995;74(3):324-331.
OBJECTIVE--To examine the determinants of case fatality in the first major ischaemic heart disease event (heart attack) after screening. METHODS--Prospective study of 7735 middle aged men drawn from general practices in 24 British towns. RESULTS--During 11.5 years follow up there were 743 major ischaemic heart disease events of which 302 (40.6%) were fatal within 28 days of onset. Previous definite myocardial infarction or stroke and age at time of event were most strongly associated with case fatality. In men with no previous myocardial infarction or stroke, after adjustment for a range of risk factors, antihypertensive treatment (odds ratio (OR) = 1.97, P < 0.05), arrhythmia (OR = 1.93, P = 0.06), increased heart rate (OR = 2.03, P = 0.06), and diabetes (OR = 2.61, P = 0.07) were associated with increased case fatality. High levels of physical activity (OR = 0.53, P < 0.05) and moderate drinking (16-42 units/week) (OR = 0.61, P < 0.05) were associated with lower case fatality, although moderate drinking was not associated with a lower incidence of major ischaemic heart disease events. Current smoking, serum total cholesterol, and systolic blood pressure were not significantly associated with case fatality. In men with previous myocardial infarction or stroke, arrhythmia and to a lesser degree antihypertensive treatment, moderate or heavy drinking, and diabetes were associated with higher case fatality. CONCLUSION--These findings suggest that physical activity may be an important modifiable factor influencing the incidence of ischaemic heart disease and the chance of survival in men without a previous heart attack or stroke. Arrhythmia, increased heart rate, diabetes, and treatment for hypertension are also areas of concern.
PMCID: PMC484027  PMID: 7547031
8.  Low serum total cholesterol concentrations and mortality in middle aged British men. 
BMJ : British Medical Journal  1995;311(7002):409-413.
OBJECTIVE--To examine the relation between low serum total cholesterol concentrations and causes of mortality. DESIGN--Cohort study of men followed up for an average of 14.8 years (range 13.5-16.0 years). SETTING--One general practice in each of 24 British towns. SUBJECTS--7735 men aged 40-59 at screening selected at random from the 24 general practices. MAIN OUTCOME MEASURES--Deaths from all causes, cardiovascular causes, cancer, and non-cardiovascular, non-cancer causes. RESULTS--During the mean follow up period of 14.8 years there were 1257 deaths from all causes, 640 cardiovascular deaths, 433 cancer deaths, and 184 deaths from other causes. Low serum cholesterol concentrations (< 4.8 mmol/l), present in 5% (n = 410) of the men, were associated with the highest mortality from all causes, largely due to a significant increase in cancer deaths (age adjusted relative risk 1.6 (95% confidence interval 1.1 to 2.3); < 4.8 v 4.8-5.9 mmol/l) and in other non-cardiovascular deaths (age adjusted relative risk 1.9 (1.1 to 3.1)). Low serum cholesterol concentration was associated with an increased prevalence of several diseases and indicators of ill health and with lifestyle characteristics such as smoking and heavy drinking. After adjustment for these factors in the multivariate analysis the increased risk for cancer was attenuated (relative risk 1.4 (0.9 to 2.0) and the inverse association with other non-cardiovascular, non-cancer causes was no longer significant (relative risk 1.5 (0.9 to 2.6); < 4.8 v 4.8-5.9 mmol/l). The excess risks of cancer and of other non-cardiovascular deaths were most pronounced in the first five years and became attenuated and non-significant with longer follow up. By contrast, the positive association between serum total cholesterol concentration and cardiovascular mortality was seen even after more than 10 years of follow up. CONCLUSION--The association between comparatively low serum total cholesterol concentrations and excess mortality seemed to be due to preclinical cancer and other non-cardiovascular diseases. This suggests that public health programmes encouraging lower average concentrations of serum total cholesterol are unlikely to be associated with increased cancer or other non-cardiovascular mortality.
PMCID: PMC2550486  PMID: 7640584
9.  Prospective study of risk factors for development of non-insulin dependent diabetes in middle aged British men. 
BMJ : British Medical Journal  1995;310(6979):560-564.
OBJECTIVE--To determine the risk factors for noninsulin dependent diabetes in a cohort representative of middle aged British men. DESIGN--Prospective study. SUBJECTS AND SETTINGS--7735 men aged 40-59, drawn from one group practice in each of 24 towns in Britain. Known and probable cases of diabetes at screening (n = 158) were excluded. MAIN OUTCOME MEASURES--Non-insulin dependent diabetes (doctor diagnosed) over a mean follow up period of 12.8 years. RESULTS--There were 194 new cases of non-insulin dependent diabetes. Body mass index was the dominant risk factor for diabetes, with an age adjusted relative risk (upper fifth to lower fifth) of 11.6; 95% confidence interval 5.4 to 16.8. Men engaged in moderate levels of physical activity had a substantially reduced risk of diabetes, relative to the physically inactive men, after adjustment for age and body mass index (0.4; 0.2 to 0.7), an association which persisted in full multivariate analysis. A nonlinear relation between alcohol intake and diabetes was observed, with the lowest risk among moderate drinkers (16-42 units/week) relative to the baseline group of occasional drinkers (0.6; 0.4 to 1.0). Additional significant predictors of diabetes in multivariate analysis included serum triglyceride concentration, high density lipoprotein cholesterol concentration (inverse association), heart rate, uric acid concentration, and prevalent coronary heart disease. CONCLUSION--These findings emphasise the interrelations between risk factors for non-insulin dependent diabetes and coronary heart disease and the potential value of an integrated approach to the prevention of these conditions based on the prevention of obesity and the promotion of physical activity.
PMCID: PMC2548938  PMID: 7888929
11.  Asymptomatic hyperglycaemia and major ischaemic heart disease events in Britain. 
OBJECTIVE--To examine the association between non-fasting serum glucose concentrations and major ischaemic heart disease (IHD) events (fatal and non-fatal myocardial infarction). DESIGN--A prospective study. SUBJECTS--A population based sample of 7735 middle aged British men. Known diabetics, men with a glucose concentration > or = 11.1 mmol/l at screening, and hypertensive patients taking regular medication were excluded from the analysis. With exclusions (n = 509) and missing glucose values (n = 49), there were 7177 men available for analysis. MAIN OUTCOME MEASURES--Major IHD events (fatal and non-fatal myocardial infarction) during 9.5 years follow up on all men. RESULTS--There were 505 major IHD events, 222 fatal and 283 non-fatal, in the 7177 men studied. There was a non-linear relation between the glucose concentration and the risk (per 1000 men per year) of all major IHD events and fatal IHD events, with the excess risk in the upper quintile of the glucose distribution (> or = 6.1 mmol/l). The unadjusted relative risks (RR) in the upper glucose concentration quintile compared with the first to the fourth quintiles combined were 1.4 (95% CI 1.1, 1.7) for all events and 1.3 (95% CI 1.0, 1.7) for fatal events. Adjustment for age, smoking, occupational status, body mass index, physical activity, systolic blood pressure, total and high density lipoprotein cholesterol, and triglyceride concentrations had a minimal effect on these relative risk estimates. This non-linear relationship between the serum glucose concentration and the risk of a major IHD event was observed in men with no evidence of IHD at screening (n = 5518) but not in men with IHD (n = 1659). In the former group, the RR (adjusted for major coronary risk factors) for all major IHD events in the upper quintile relative to the lower quintiles combined was 1.5 (95% CI 1.2, 2.0) and for fatal IHD events was 1.8 (95% CI 1.1, 2.6). CONCLUSION--These data suggest that asymptomatic hyperglycaemia is an independent risk factor for major IHD events.
PMCID: PMC1060028  PMID: 7830006
12.  Loss of employment and mortality. 
BMJ : British Medical Journal  1994;308(6937):1135-1139.
OBJECTIVE--To assess effect of unemployment and early retirement on mortality in a group of middle aged British men. DESIGN--Prospective cohort study (British Regional Heart Study). Five years after initial screening, information on employment experience was obtained with a postal questionnaire. SETTING--One general practice in each of 24 towns in Britain. SUBJECTS--6191 men aged 40-59 who had been continuously employed for at least five years before initial screening in 1978-80: 1779 experienced some unemployment or retired during the five years after screening, and 4412 remained continuously employed. MAIN OUTCOME MEASURE--Mortality during 5.5 years after postal questionnaire. RESULTS--Men who experienced unemployment in the five years after initial screening were twice as likely to die during the following 5.5 years as men who remained continuously employed (relative risk 2.13 (95% confidence interval 1.71 to 2.65). After adjustment for socioeconomic variables (town and social class), health related behaviour (smoking, alcohol consumption, and body weight), and health indicators (recall of doctor diagnoses) that had been assessed at initial screening the relative risk was slightly reduced, to 1.95 (1.57 to 2.43). Even men who retired early for reasons other than illness and who appeared to be relatively advantaged and healthy had a significantly increased risk of mortality compared with men who remained continuously employed (relative risk 1.87 (1.35 to 2.60)). The increased risk of mortality from cancer was similar to that of mortality from cardiovascular disease (adjusted relative risk 2.07 and 2.13 respectively). CONCLUSIONS--In this group of stably employed middle aged men loss of employment was associated with an increased risk of mortality even after adjustment for background variables, suggesting a causal effect. The effect was non-specific, however, with the increased mortality involving both cancer and cardiovascular disease.
PMCID: PMC2540120  PMID: 8173455
13.  Ischaemic heart disease: association with haematocrit in the British Regional Heart Study. 
OBJECTIVES--To assess the relationship between haematocrit and risk of major ischaemic heart disease events. DESIGN--Prospective study of a cohort of men followed up for 9.5 years. SETTING--General practices in 24 towns in England, Wales, and Scotland (British Regional Heart Study). SUBJECTS--Altogether 7735 men aged 40-59 years at screening, who were selected at random from one general practice in each of 24 towns, were studied. MAIN OUTCOME MEASURES--Fatal and nonfatal ischaemic heart disease events. RESULTS--Risk of major ischaemic heart disease events was significantly increased at haematocrit levels of > or = 46.0%. Men with raised haematocrit (> or = 46.0%) showed a 30% increase in relative risk (RR) of major ischaemic heart disease events (RR = 1.32; 95% confidence intervals (CI) 1.10,1.57, p < 0.01) compared with those with values below 46.0%, even after adjustment for age, social class, smoking, body mass index, physical activity, blood cholesterol, lung function (FEV1), and pre-existing evidence of ischaemic heart disease. Further adjustment for systolic blood pressure reduced the risk slightly (RR = 1.27; 95% CI 1.06,1.51, p = 0.02) but it remained significant. The relationship was seen in men with and without pre-existing evidence of ischaemic heart disease. The study suggests that an increased haematocrit level plays a part in the development of major ischaemic heart disease events.
PMCID: PMC1059917  PMID: 8189162
14.  Alcohol intake and mortality. 
BMJ : British Medical Journal  1994;308(6928):598.
PMCID: PMC2539603  PMID: 8204180
15.  Weight change, perceived health status and mortality in middle-aged British men. 
Postgraduate Medical Journal  1990;66(781):910-913.
The association between weight change over a 5-year period, the subsequent perception of health and the mortality during a 4-year follow-up period has been examined in a prospective study of 7735 middle-aged British men. There were 357 deaths from all causes. Self-assessment of health status was considered as a potential guide to whether weight loss was intended or involuntary. Irrespective of weight change those who reported poor or fair health had a more than two-fold increase in death rate compared to those who reported good or excellent health. Considerable weight gain (greater than 10%) was associated with high rates of cardiovascular disease regardless of health perception, although this was most marked in those who perceived poor or fair health. Moderate weight gain was of little importance except in those who regarded their health as poor or fair. Weight loss was associated with increased death rates from cancer regardless of health perception, although the rates were highest in those who perceived poor or fair health. This study emphasizes that weight loss is a potentially serious symptom even in men who report good health. Assessment of weight change and of perception of health status are both of value and could be used in standard health enquiries to monitor health status in individuals and the community.
PMCID: PMC2429739  PMID: 2267201
17.  Heart rate, ischaemic heart disease, and sudden cardiac death in middle-aged British men. 
British Heart Journal  1993;70(1):49-55.
OBJECTIVE--To examine the relation between resting heart rate and new major ischaemic heart disease events in middle aged men with and without pre-existing ischaemic heart disease. DESIGN--Prospective study of a cohort of men with eight years follow up for cardiovascular morbidity and mortality for all men. SETTING--General practices in 24 British towns (the British Regional Heart study). SUBJECTS--7735 men aged 40-59 years drawn at random from the age-sex registers of one general practice in each town. MAIN OUTCOME MEASURES--Major ischaemic heart disease events such as sudden cardiac death, other deaths attributed to ischaemic heart disease, and non-fatal myocardial infarction. RESULTS--During the follow up period of eight years, 488 men had a major ischaemic heart disease event (217 fatal and 271 non-fatal). Of these, 117 were classified as sudden cardiac death (death within one hour of the start of symptoms). The relation between heart rate and risk of all major ischaemic heart disease events, ischaemic heart disease deaths, and sudden cardiac death was examined separately in men with and without pre-existing ischaemic heart disease. In men with no evidence of ischaemic heart disease, there was a strong positive association between resting heart rate and age adjusted rates of all major ischaemic heart disease events (fatal and non-fatal), ischaemic heart disease deaths, and sudden cardiac death. This association remained significant even after adjustment for age, systolic blood pressure, blood cholesterol, smoking, social class, heavy drinking, and physical activity, with particularly high risk in those with heart rate > or = 90 beats/min. The increased risk seen in those with increased heart rate was largely due to a significantly increased risk of sudden cardiac death, which was five times higher than in those with heart rate < 60 beats/min. The effect of heart rate on sudden cardiac death was present irrespective of blood pressure or smoking state. In men with pre-existing ischaemic heart disease a positive association was seen between raised heart rate and risk of all major ischaemic heart disease events, ischaemic heart disease death, and sudden cardiac death, but the effect was less noticeable than in men without pre-existing ischaemic heart disease. CONCLUSION--In this study of middle aged British men increased heart rate > or = 90 beats/min) is a risk factor for fatal ischaemic heart disease events but particularly for sudden cardiac death. The effect is not dependent on the presence of other established coronary risk factors and is most clearly seen in men free of pre-existing ischaemic heart disease at initial examination.
PMCID: PMC1025228  PMID: 8037998
18.  Alcohol and sudden cardiac death 
British Heart Journal  1992;68(5):443-448.
Objective—To assess the relation between alcohol intake and sudden cardiac death—ie, death within one hour of the onset of symptoms.
Design—Prospective study of a cohort of men followed up for eight years.
Setting—General practices in 24 towns in England, Wales, and Scotland.
Subjects—7735 men aged 40–59 at screening who were selected at randon from one general practice in each of 24 towns.
Main outcome measure—All deaths from ischaemic heart disease with particular reference to those that were sudden (death within one hour of the onset of symptoms).
Results—During the follow up period of eight years there were 217 deaths from ischaemic heart disease of which 117 (54%) were classified as sudden. Although heavy drinkers (more than six drinks daily) did not show a high incidence rate of fatal heart attack, they showed the highest incidence rate of sudden cardiac death. This was seen in both manual and non-manual workers and was most clearly seen in older (50–59) men. Death from ischaemic heart disease was more likely to be sudden in heavy drinkers than in other drinking groups; this phenomenon was seen irrespective of the presence or degree of pre-existing ischaemic heart disease. The positive association between heavy drinking and the incidence of sudden death was most apparent in men without pre-existing ischaemic heart disease, with heavy drinkers showing an increase of >60% compared with occasional or light drinkers. After adjustment for age, social class, and smoking, heavy drinkers free of pre-existing ischaemic heart disease had a marginally significantly higher incidence rates of sudden death than other drinkers combined (relative risk 2·00, 95% confidence interval 0·98 to 4·8). Additional adjustment for systolic blood pressure reduced the risk to 1·7.
Conclusions—This study suggests that heavy drinking is associated with an increased risk of sudden death. Studies that do not take pre-existing ischaemic heart disease into account are likely to underestimate the adverse effects of heavy drinking on the incidence of sudden death because the effects are not as evident in men with pre-existing ischaemic heart disease.
PMCID: PMC1025184  PMID: 1467026
19.  Blood lipids: the relationship with alcohol intake, smoking, and body weight. 
STUDY OBJECTIVE--The aim was to assess the interrelationship between alcohol intake, cigarette smoking, body weight, and blood lipid concentrations. DESIGN--This was the cross sectional (screening) phase of a prospective study. The main outcome measure was the blood lipids (serum total cholesterol, HDL cholesterol, and triglycerides). SETTING--General practices in 24 towns (The British Regional Heart Study). SUBJECTS--Subjects were 7735 men aged 40-59 years, selected at random from the age-sex registers of one group practice in each of the 24 towns. RESULTS--Univariate analysis showed little association between alcohol intake and total cholesterol, a strong positive relation with HDL cholesterol, and a significant increase in triglycerides in heavy drinkers. A strong positive association between alcohol intake and body weight was present in non-smokers but not in moderate/heavy smokers. With the exception of HDL cholesterol, the relationships between alcohol intake and serum lipids were significantly different in smokers and non-smokers, apparently due to the opposing effect of smoking on blood lipids and body weight. Total cholesterol and triglycerides were significantly and positively associated with alcohol intake in non-smokers, the cholesterol association being largely mediated by the influence of alcohol on body weight. In smokers, no such association was seen: current smokers who were heavy drinkers or non-drinkers had the lowest mean cholesterol levels. CONCLUSIONS--The association between alcohol intake and body weight and alcohol intake and blood lipids are strongly conditioned by cigarette smoking. Simple standardisation for smoking in multivariate analyses may obscure the independent relationship with alcohol. These findings are of importance in studies seeking to relate alcohol intake, body weight, or cigarette smoking to blood lipid concentrations, or blood lipid concentration to morbidity or mortality.
PMCID: PMC1059549  PMID: 1645070
20.  The Dinamap 1846SX automated blood pressure recorder: comparison with the Hawksley random zero sphygmomanometer under field conditions. 
STUDY OBJECTIVE--The aim was to compare the performance of the Dinamap 1846SX automated oscillometric blood pressure recorder with that of the Hawksley random zero sphygmomanometer during use under field study conditions. DESIGN--Two independent within subject measurement comparisons were made, one in adults and one in children, each conducted in three stages over several months while the Dinamap instruments were being used in epidemiological field surveys. SETTING--The studies were done in outpatients clinics (adults) and primary schools (children). PARTICIPANTS--141 adults (20-85 years) and 152 children (5-7 years) took part. MEASUREMENTS AND MAIN RESULTS--In adults a pair of measurements was made with each instrument, the order alternating for consecutive subjects. In children one measurements was made with each instrument, in random order. Measurements with the Dinamap 1846SX were higher than those with the random zero sphygmomanometer both in adults (mean difference 8.1 mm Hg; 95% CI 6.5 to 9.7 mm Hg) and in children (mean difference 8.3 mm Hg; 95% CI 6.9 to 9.7 mm Hg). Diastolic measurements were on average very similar both in adults and in children. The results were consistent at all three stages of both studies. The differences in systolic measurement were independent of blood pressure level. However, the extent of agreement in diastolic pressure depended on the diastolic blood pressure level; in both studies Dinamap diastolic measurements were higher at low diastolic pressures while random zero diastolic measurements were higher at high diastolic pressures. CONCLUSIONS--Systolic measurements made with the Dinamap 1846SX instrument are not directly comparable with those of the Hawksley random zero sphygmomanometer and are unlikely to be comparable with those of earlier Dinamap models. These differences have important implications for clinical practice and for comparisons of blood pressure measurement between epidemiological studies. However, the consistency of measurement by the Dinamap 1846SX over time suggests that the instrument may have a place in standardised blood pressure measurement in the research setting.
PMCID: PMC1059528  PMID: 1583434
21.  Physical activity and stroke in British middle aged men. 
BMJ : British Medical Journal  1992;304(6827):597-601.
OBJECTIVES--To assess the relation between physical activity and stroke and to determine the overall benefit of physical activity for all major cardiovascular events. DESIGN--Prospective study of a cohort of men followed up for 9.5 years. SETTING--General practices in 24 towns in England, Wales, and Scotland (British regional heart study). SUBJECTS--7735 men aged 40-59 at screening, selected at random from one general practice in each of 24 towns. MAIN OUTCOME MEASURES--Fatal and non-fatal strokes and heart attacks. RESULTS--128 major strokes (fatal and non-fatal) occurred. Physical activity was inversely associated with risk of stroke independent of coronary risk factors, heavy drinking, and pre-existing ischaemic heart disease or stroke (relative risk 1.0 for inactivity, 0.6 moderate activity, and 0.3 vigorous activity; test for trend p = 0.008). The association remained after excluding men reporting regular sporting (vigorous) activity. However, vigorous physical activity was associated with a marginally significant increased risk of heart attack compared with moderate or moderately vigorous activity in men with no pre-existing ischaemic heart disease or stroke (relative risk 1.6%; 95% confidence interval 0.96 to 2.8). In men with symptomatic ischaemic heart disease or stroke those doing moderately vigorous or vigorous activity had a risk of heart attack slightly higher than that in inactive men (relative risk = 1.6; 0.8 to 3.3). CONCLUSIONS--Moderate physical activity significantly reduces the risk of stroke and heart attacks in men both with and without pre-existing ischaemic heart disease. More vigorous activity did not confer any further protection. Moderate activity, such as frequent walking and recreational activity or weekly sporting activity, should be encouraged without restriction.
PMCID: PMC1881358  PMID: 1559088
22.  Non-employment and changes in smoking, drinking, and body weight. 
BMJ : British Medical Journal  1992;304(6826):536-541.
OBJECTIVE--To assess the effect of unemployment and early retirement on cigarette smoking, alcohol consumption, and body weight in middle aged British men. DESIGN--Prospective cohort study (British regional heart study). SETTING--One general practice in 24 towns in Britain. SUBJECTS--6057 men aged 40-59 who had been continuously employed for five years before the initial screening. Five years after screening 4412 men had been continuously employed and 1645 had experienced some unemployment or retired. MAIN OUTCOME MEASURES--Numbers of cigarettes smoked and units of alcohol consumed per week and body mass index (kg/m2). RESULTS--An initial screening significantly higher percentages of men who subsequently experienced non-employment smoked or had high alcohol consumption than of men who remained continuously employed: 43.0% versus 37.0% continuously employed for cigarette smoking (95% confidence interval for difference 3.2% to 9.0%) and 12.1% versus 9.0% for heavy drinking (1.3% to 5.1%). There was no evidence that men increased their smoking or drinking on becoming non-employed. Men non-employed through illness were significantly more likely to reduce their smoking and drinking than men who remained continuously employed. Men who experienced non-employment were significantly more likely to gain over 10% in weight than men who remained continuously employed: 7.5% versus 5.0% continuously employed (0.9% to 4.0%). CONCLUSIONS--Loss of employment was not associated with increased smoking or drinking but was associated with an increased likelihood of gaining weight. The long term effects of the higher levels of smoking and alcohol consumption before nonemployment should be taken into account when comparing mortality and morbidity in groups of unemployed and employed people.
PMCID: PMC1881409  PMID: 1559056
24.  Estimating the risk of heart attack. 
BMJ : British Medical Journal  1991;303(6813):1333-1334.
PMCID: PMC1671424  PMID: 1747683
25.  Physical activity and ischaemic heart disease in middle-aged British men. 
British Heart Journal  1991;66(5):384-394.
OBJECTIVE--To assess the relation between reported physical activity and the risk of heart attacks in middle aged British men. DESIGN--Prospective study of middle-aged men followed for a period of eight years (The British Regional Heart Study). SETTING--One general practice in each of 24 British towns. PARTICIPANTS--7735 men aged 40-59 years at initial examination. END POINT--Heart attacks (non-fatal and fatal). MEASUREMENTS AND MAIN RESULTS--During the follow up period of eight years 488 men suffered at least one major heart attack. A physical activity score used was developed and validated against heart rate and lung function (FEV1) in men without evidence of ischaemic heart disease. Risk of heart attack decreased significantly with increasing physical activity; the groups reporting moderate and moderately vigorous activity experienced less than half the rate seen in inactive men. The benefits of physical activity were seen most consistently in men without preexisting ischaemic heart disease and up to levels of moderately vigorous activity. Vigorously active men had higher rates of heart attack than men with moderate or moderately vigorous activity. The relation between physical activity and the risk of heart attack seemed to be independent of other cardiovascular risk factors. Men with symptomatic ischaemic heart disease showed a reduction in the rate of heart attack at light or moderate levels of physical activity, beyond which the risk of heart attack increased. Men with asymptomatic ischaemic heart disease showed an increasing risk of heart attack with increasing levels of physical activity, but with a progressive decrease in case fatality. Overall, men who engaged in vigorous (sporting) activity of any frequency had significantly lower rates of heart attack than men who reported no sporting activity. However, when all men reporting regular sporting activity at least once a month were excluded from analysis, there remained a strong inverse relation between physical activity and the risk of heart attack in men without pre-existing ischaemic heart disease. CONCLUSION--This study suggests that the overall level of physical activity is an important independent protective factor in ischaemic heart disease and that vigorous (sporting) exercise, although beneficial in its own right, is not essential in order to obtain such an effect.
PMCID: PMC1024782  PMID: 1747302

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