Data alert The INTERHEART Study: New data on global risk Cardiovascular disease (CVD) is estimated to be the leading cause of mortality and morbidity worldwide. This paper has now been published in the print journal. For full text please go to http://dx.doi.org/10.1016/S0140-678-9.

Contents • • • • • • • • • • • • • • • • • • • Clinical Question Among a global population of patients, what proportion of risk of first myocardial infarction is attributable to modifiable risk factors? Bottom Line Nine modifiable risk factors, including dyslipidemia, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits and vegetables, alcohol use, and regular physical activity account for over 90% of the risk of first myocardial infarction. Major Points Modifiable cardiovascular risk factors have been well established in populations of European origin in high-income countries. However, 80% of the global burden of cardiovascular disease are in low and middle income countries. It is unclear whether these results can be applied worldwide across different geographic regions and ethnicities. Not only may risk factors for coronary artery disease vary between populations, prevalence of risk factors may differ as well. Published in 2004, The Effect of Potentially Modifiable Risk Factors Associated with Myocardial Infarction (INTERHEART) case-control study enrolled 15,152 cases and 14,820 age and sex matched controls worldwide across all six habitable continents.

Cases were defined as patients with a first myocardial infarction, and controls as patients without a history of exertional chest pain or history of coronary artery disease. Nine risk factors, including smoking, raised ApoB/ApoA1 ratio, hypertension, diabetes, abdominal obesity, psychosocial factors, daily fruits and vegetables, and regular physical activity collectively accounted for 90% of the population attributable risk (PAR) in men and 94% of the PAR in women. These associations remained present across ethnicities and geographic regions. This landmark epidemiological study suggested that the majority of first acute myocardial infarctions can be prevented with modification of these nine risk factors.

The three most important cardiovascular risk factors globally were a high ApoB/ApoA1 ratio (PAR 49.2%), a history of smoking (PAR 35.7%), and psychosocial factors (PAR 32.5%). The former two risk factors alone account for two thirds of the PAR alone, and risk for both variables increase in a dose-dependent manner. Protective risk factors included alcohol intake, daily fruits and vegetables, and exercise.

Lifestyle modifications, including exercise, daily fruits and vegetables, alcohol intake, and smoking are responsible for half of the PAR (55%). While most associations between the nine risk factors and cardiovascular disease was strong (p40 cigarettes are smoked daily, OR = 9.16 • ApoB/ApoA1 ratio: A linear relationship between the deciles of ApoB/A1 ratio and OR is demonstrated. At the highest decile, the OR is 1.28. At the lowest decile, the OR is 0.43.

Subgroup Analysis • Gender, Male vs. Female (PARs) • Smoking: 42.7% vs.

14.8% • Fruits and vegetables: 11.7% vs. 19.1% • Exercise: 9.3% vs. 27.1% • Alcohol: 5.1% vs. 22.1% • All lifestyle: 56.5% vs. 60.6% • Hypertension: 14.9% vs. 29.0% • Diabetes: 8.0% vs.

16.1% • Abdominal obesity: 19.7% vs. 18.7% • All psychosocial: 28.8% vs. 45.2% • Lipids: 49.5% vs.

47.1% • All nine risk factors: 90% vs. 94% • Age, young (55y) (ORs) • Only statistically significant (P. Ibm Data Studio 4.1 here.