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Clarifying the Direct Relation between Total Cholesterol Levels and Death from Coronary Heart Disease in Older Persons

Maria-Chiara Corti, MD, MHS; Jack M. Guralnik, MD, PhD; Marcel E. Salive, MD, MPH; Tamara Harris, MD, MS; Luigi Ferrucci, MD, PhD; Robert J. Glynn, ScD; and Richard J. Havlik, MD, MPH
[+] Article and Author Information

For author affiliations and current author addresses, see end of text. Grant Support: In part by contracts N01-AG-02105, N01-AG-02106, and N01-AG-02107 from the National Institute on Aging, Bethesda, Maryland. Requests for Reprints: Maria-Chiara Corti, MD, MHS, Epidemiology, Demography, and Biometry Program, National Institute on Aging, National Institutes of Health, 7201 Wisconsin Avenue, Gateway Building, Room 3C-309, Bethesda, MD 20892-9205. Current Author Addresses: Drs. Corti, Guralnik, Harris, and Havlik: Epidemiology, Demography, and Biometry Program, National Institute on Aging, 7201 Wisconsin Avenue, 3C-309, Bethesda, MD 20892.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1997;126(10):753-760. doi:10.7326/0003-4819-126-10-199705150-00001
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Background: The importance of total cholesterol level as a risk factor for coronary heart disease in older adults is controversial.

Objective: To determine whether findings showing that total cholesterol level is not an important risk factor for coronary heart disease in older adults are the result of inadequate adjustment for co-occurring diseases and frailty.

Design: Multicenter, longitudinal study with 5-year follow-up for death.

Participants: 4066 men and women from East Boston, Massachusetts; lowa and Washington counties, lowa; and New Haven, Connecticut.

Measurements: In 1988, participants were interviewed about their health status and had blood samples taken. Mortality follow-up was through 1992.

Results: In analyses that included all fatal coronary heart disease events (252 deaths) and did not adjust for risk factors for coronary heart disease and measures of frailty, persons with the lowest total cholesterol levels (≤ 4.15 mmol/L [≤ 160 mg/dL]) had the highest rate of death from coronary heart disease, whereas those with elevated total cholesterol levels (≥ 6.20 mmol/L [≥ 240 mg/dL]) seemed to have a lower risk for death from coronary heart disease (P for trend = 0.04). After adjustment for established risk factors for coronary heart disease and markers of poor health (including chronic conditions, low serum iron and albumin levels) and exclusion of 44 deaths from coronary heart disease that occurred within the first year, elevated total cholesterol levels predicted increased risk for death from coronary heart disease, and the risk for death from coronary heart disease decreased as cholesterol levels decreased (P for trend = 0.005).

Conclusions: Elevated total cholesterol level is a risk factor for death from coronary heart disease in older adults, and the apparent adverse effects associated with low cholesterol levels are secondary to comorbidity and frailty. This suggests that excluding older persons from cholesterol screening is inappropriate, but interpretation of screening results in older persons requires clinical judgment. Results from controlled clinical trials are needed to clarify this issue.

Figures

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Figure 1.
Relative risks for death from coronary heart disease (CHD) according to total cholesterol level before and after stepwise inclusion of adjustment variables and exclusion of first-year events.Top left.Top right.Bottom left.Bottom right.

Relative risks are from four separate community-stratified proportional-hazard models. Model 1 is adjusted for high-density lipoprotein (HDL) cholesterol levels only and includes all events. Model 2 is adjusted for age, sex, and risk factors for coronary heart disease and includes all events. Model 3 is adjusted for age, sex, risk factors for coronary heart disease, and serum iron and albumin levels and includes all events. Model 4 is adjusted for age, sex, risk factors for coronary heart disease, and serum iron and albumin levels and excludes first-year events. Risk factors for coronary heart disease include HDL cholesterol level; isolated systolic hypertension; diastolic hypertension; alcohol consumption; smoking; and history of high blood pressure, diabetes, heart attack, and stroke.

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