Nemetz, Peter N.

The importance of coronary artery disease (CAD) surveillance, as recently underscored by the American Heart Association, is heightened by the obesity/diabetes epidemics. The need for surveillance is especially great for subclinical CAD, as the greatest increases in obesity/diabetes are occurring among younger age groups, where clinically-recognized CAD is infrequent. Yet few methods for such population-based surveillance exist. Using one such method, unbiased heart autopsy data, we previously showed that declines in grade of CAD observed since 1981 ended in the mid-1990s and may have reversed. In order to assess and interpret the factors underlying these observations, it is necessary to first examine trends in CAD risk factors among heart autopsied decedents and investigate the extent to which they mirror trends in the general population. Rochester Epidemiology Project (REP) medical records linkage resources were used to identify 1) all Olmsted County residents age 16-64 years who died from non-natural causes and went to autopsy 1981-2009 (96% autopsy rate) and 2) all Olmsted County residents age 16-64 years 1981-2009. We randomly selected two population subjects per decedent, stratified by calendar year. All REP inpatient/ ambulatory records were reviewed for CAD risk factors. Compared to population subjects, decedents were older and more likely to be male, smokers, alcohol abusers, and treated for hypertension; however, risk factor trends for both groups were generally of similar magnitude and direction, i.e., smoking, alcohol use, and blood pressure declined and anti-hypertensive medication use, diagnosed hyperlipidemia, and body mass index increased ( Table ). These population-based longitudinal data indicate that temporal trends in risk factors among autopsied decedents parallel those for the general population, supporting the concept that data on autopsied decedents can provide insight into trends in CAD risk and the changing burden of atherosclerosis within the source population. Characteristics of all 1) non-elderly adult Olmsted County residents who died non-natural deaths and were autopsied and 2) non-elderly adult Olmsted County residents with respect to CAD risk factors and calendar year trends CAD Risk Factor Autopsied Decedents (N=315) Population Subjects (N=672) P Value Autopsied Decedents, Temporal Trend Population Subjects, Temporal Trend N Calendar Year Estimate P value N Calendar Year Estimate P Value Age at Index, Mean (SD) 37.5 (14.0) 34.1 (13.6) <0.01 1 315 0.172 0.06 1 672 −0.059 0.33 1 Sex, % Male 236 (75%) 339 (50%) <0.01 2 315 0.008 0.60 2 672 −0.008 0.39 2 Race, % Non-White 29 (9%) 85 (13%) 0.14 3 305 0.054 0.04 3 589 0.023 0.12 3 Of Ever Smokers, Current = Yes 128/184 (70%) 118/210 (56%) 0.01 3 184 −0.040 0.048 3 210 −0.052 <0.01 3 Of Ever Alcohol Use, Current = Yes 175/238 (74%) 284/364 (78%) 0.08 3 238 −0.065 <0.01 3 364 −0.027 0.09 3 Mention of Alcoholism, Yes 80 (25%) 41 (6%) <0.01 3 315 0.014 0.35 3 672 0.042 0.04 3 Closest Systolic BP, Mean (SD) 124.1 (16.6) 120.3 (15.7) 0.34 3 285 −0.179 0.09 3 600 −0.156 0.02 3 Closest Diastolic BP, Mean (SD) 76.2 (11.6) 74.0 (10.5) 0.53 3 285 −0.194 0.01 3 600 −0.112 0.02 3 Closest BP on Medication, Yes 44 (14%) 36 (5%) <0.01 3 283 0.046 0.03 3 599 0.063 <0.01 3 Hyperlipidemia Diagnosis, Yes 32 (10%) 65 (10%) 0.32 3 315 0.114 <0.01 3 672 0.078 <0.01 3 Closest Fasting Glucose, Mean (SD) 95.8 (26.0) 95.0 (27.6) 0.63 3 177 0.270 0.23 3 335 0.505 <0.01 3 Closest BMI, Mean (SD) 26.1 (5.8) 25.9 (5.4) 0.52 3 280 0.080 0.04 3 593 0.091 <0.01 3 1 Unadjusted, Chi-square; 2 Unadjusted, Wilcoxon rank sum test; 3 Adjusted for age and sex, linear or logistic regression; BP = Blood Pressure; BMI = Body Mass Index

Background Our previous study of nonelderly adult decedents with nonnatural (accident, suicide, or homicide) cause of death (96% autopsy rate) between 1981 and 2004 revealed that the decline in subclinical coronary artery disease ( CAD ) ended in the mid‐1990s. The present study investigated the contributions of trends in obesity and diabetes mellitus to patterns of subclinical CAD and explored whether the end of the decline in CAD persisted. Methods and Results We reviewed provider‐linked medical records for all residents of Olmsted County, Minnesota , who died from nonnatural causes within the age range of 16 to 64 years between 1981 and 2009 and who had CAD graded at autopsy. We estimated trends in CAD risk factors including age, sex, systolic blood pressure, diabetes (qualifying fasting glucose or medication), body mass index, smoking, and diagnosed hyperlipidemia. Using multiple regression, we tested for significant associations between trends in CAD risk factors and CAD grade and assessed the contribution of trends in diabetes and obesity to CAD trends. The 545 autopsied decedents with recorded CAD grade exhibited significant declines between 1981 and 2009 in systolic blood pressure and smoking and significant increases in blood pressure medication, diabetes, and body mass index ≥30 kg/m 2 . An overall decline in CAD grade between 1981 and 2009 was nonlinear and ended in 1994. Trends in obesity and diabetes contributed to the end of CAD decline. Conclusions Despite continued reductions in smoking and blood pressure values, the previously observed end to the decline in subclinical CAD among nonelderly adult decedents was apparent through 2009, corresponding with increasing obesity and diabetes in that population.